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Online Installment Payment Arrangement

Online Installment Payment Arrangement

  • Your application will automatically be emailed to the clinic you select in the drop-down menu.
  • *If the patient is under the age of 18.
  • I, the undersigned patient, acknowledge that I have an outstanding account balance with SeMRHI in the amount of $_________which is payable immediately.
  • In consideration of the agreement of SeMRHI to permit payment of the balance in deferred installments, I agree to pay the Clinic installments of $_____________ per month.
  • I agree to make my payments on or before _______________, 20____, and continuing on or before the same day of each following month until the balance is paid in full.
    Date Format: MM slash DD slash YYYY
  • Guidelines are as follows:

    Payments must be made consecutively each month. If payment is not made, the account will automatically be turned over to collections.
  • Our Mission

    To provide access to affordable quality primary and preventive health care to our communities in a patient centered, safe, compassionate environment. Equal Opportunity Provider
  • This field is for validation purposes and should be left unchanged.
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