Online Installment Payment Arrangement Online Installment Payment Arrangement Your application will automatically be emailed to the clinic you select in the drop-down menu.Clinic LocationBeaumont Family Health CenterBrooklyn Family Health CenterHattiesburg Family Health CenterHattiesburg High School Campus ClinicHattiesburg High School & Community ClinicHattiesburg Public School & Community Clinic (Lillie Burney)Lumberton Family Health CenterMinor Care ClinicNew Augusta Family Health CenterNR Burger School & Community ClinicPetal School ClinicPicayune Family Health CenterSeminary Family Health CenterSumrall Family Health CenterSupport Services Center (Behavioral Health)Patient Name:* First Middle Initial Last Account Number #:Responsible Party:*If the patient is under the age of 18. First Middle Initial Last Account Balance:Current Account Balance Amount (Please Enter Amount):I, the undersigned patient, acknowledge that I have an outstanding account balance with SeMRHI in the amount of $_________which is payable immediately.Monthly Installment Payment Arrangement Amount (Please Enter Amount):*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.Start Date of Installment Payment Arrangement:*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 Patient Acknowledgement:* I understand and agree that if I fail to pay as agreed above, SeMRHI shall have the right to demand payment of the entire balance, refer the account to a collection agency, and take other measures permitted by law. By signing below, the patient acknowledges this agreement.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.Signature of Responsible Party:*Signature of Witness (Please leave this area blank. A clinic representative will sign this area.):Our MissionTo provide access to affordable quality primary and preventive health care to our communities in a patient centered, safe, compassionate environment. Equal Opportunity Provider NameThis field is for validation purposes and should be left unchanged.