Medical Payment Plan Agreement Form

Simplify Medical Payment Plans with Paperform

Managing patient payment plans doesn't have to mean stacks of paperwork and manual follow-ups. This Medical Payment Plan Agreement Form template helps healthcare practices create clear, binding payment arrangements for patients facing high deductibles or significant out-of-pocket medical expenses.

Built for Modern Healthcare Practices

Whether you're a private practice, specialty clinic, dental office, or outpatient facility, this template streamlines the process of setting up installment payment schedules. Patients can review terms, agree to payment amounts and schedules, and provide their payment information—all in one smooth, HIPAA-friendly form experience.

The form captures essential details including patient information, total balance owed, proposed payment schedule, and automatic payment authorization. Built-in calculations can help determine monthly payment amounts based on the total balance and desired payment term, while conditional logic ensures patients see only the fields relevant to their chosen payment plan.

Automate Payment Plan Workflows with Stepper

Once a payment plan agreement is submitted, you can use Stepper—Paperform's AI-native workflow builder—to automatically route the agreement to your billing team, update your practice management system, send the patient a confirmation email with their payment schedule, and set up recurring payment reminders. Keep everything connected without manual data entry or dropped follow-ups.

Accept Payments Directly Through Paperform

Connect Stripe, PayPal, or Square to collect initial deposits or set up recurring payments right inside the form. Paperform's payment integrations make it easy to take that first payment, establish payment methods for future installments, or even set up automatic recurring billing based on the agreed schedule.

Need patients to sign off on terms? Send the completed agreement through Papersign for secure eSignatures, creating a legally binding document that's stored alongside the original form submission for complete records.

With Paperform's SOC 2 Type II compliance, secure data handling, and powerful integrations with billing systems and CRMs, medical practices get a professional, scalable solution for managing payment plans that works for both staff and patients.