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 (Last 4)*

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*

Payment Type*

Credit Card
ACH

Test Charge

Price: $1.00

Credit Card*

Card Details

Cardholder Name

Account Holder Type

Routing Number

Account Number

Confirm Account Number

Payment Plan Amount is Too Large

Payment Plan Amount is Too Small

New Enrollment (Northwest Florida Community Hospital)