Repaytient Payment Plan Enrollment Form

Name*

First Middle Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Hospital or Facility*

Social Security Number*

Date of Birth*

Email*

Phone*

Type Of Insurance*

Individual Insurance Plan
Group Insurance Plan
Medicare
None

Current Employer*

Pay Frequency*

Monthly
Twice-Monthly
Bi-Weekly
Weekly

Date of Next Pay Date*

Gross Monthly Income*

Estimated or Actual Out of Pocket Expense*

This is the amount you will owe the provider after your insurance has paid their portion.

Term Options*

6 Months

Term Options*

6 Months
12 Months

Term Options*

6 Months
12 Months
18 Months

Term Options*

12 Months
18 Months
24 Months

Term Options*

18 Months
24 Months
30 Months

Term Options*

24 Months
30 Months
36 Months

Term Options*

30 Months
36 Months
42 Months

Term Options*

36 Months
42 Months
48 Months

Term Options*

48 Months
54 Months
60 Months

Term Options*

36 Months
42 Months
48 Months

Payment Amount*

First Scheduled Payment Date*

Frequency Of Repayment*

Test Charge

Price: $1.00

Credit Card*

Card Details

Cardholder Name

Payment Plan Amount is Too Large

Payment Plan Amount is Too Small

Item ID

App ID

New Enrollment (Northwest Florida Community Hospital)