Home Towne Family Medicine (HTFM) has approved a payment plan for your convenience. Please read the following regulations, sign below to accept, and then return the contract to the Home Towne Family Medicine, ASAP.
Payments must be made with a credit or debit card. You are required to notify HTFM in writing if you would like to switch payments to a different credit/debit are. This can be submitted electronicall via the patient portal, email to firstname.lastname@example.org or by mail to 15580 3rd Ave SW, Suite 101, Burien, WA 98166.
Indicate the total amount due as of today's day below.
Your credit or debit card will be automatically charged on the day of each month you choose when activating the plan until the balance at the time of the payment plan is paid in full, the final payment may be less.
If your payment is not received or unable to process (declined) the contract will no longer be valid and the amount is due in full immediately.
Consent to bill card on file.
I have read the HOME TOWNE FAMILY MEDICINE payment contract above and agree to each guideline. I understand that I am responsible for the costs not covered by my insurance (see patient financial responsibility form for more information) and agree to the payment arrangements indicated in the existing payment plan.
This is your electronic signature.