Free Medical Bill Payment Plan Agreement PDF
Create a medical bill payment plan agreement with balance details, payment dates, and terms you can sign or email to your provider.
Published December 1, 2025
If you can’t pay a hospital or clinic bill in full, a written payment plan can prevent collections and clarify expectations. This free template helps you list the balance, installment schedule, and any late-fee or default terms before signing.
When to use this
- You need to propose installments because the full balance isn’t affordable right now.
- You want written terms to avoid surprise late fees or collection activity.
- You’re negotiating with billing staff and want a PDF you can sign and email quickly.
How to do it (fast)
- Enter the patient, provider, account number, and total balance.
- Add your first payment date, frequency, and the installment schedule.
- Include any late-fee or default language and how the provider should contact you.
- Download the PDF from CourtPDF, sign it, and share it with billing or collections staff.
Why this helps
- Shows the provider a clear, written offer with dates and amounts.
- Documents late-fee or default rules so expectations are aligned.
- Gives both sides signature lines for a simple, shareable agreement.
Related tools
Not legal advice. Courts set their own rules. Keep your original records.
Download the Medical Bill Payment Plan Agreement
Enter the balance, payment schedule, and contact preferences to create a PDF you can sign and email to billing.
Open the payment plan tool