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1. Parties: Identification of healthcare provider and patient
2. Amount Owed: Clear statement of principal amount due for medical services
3. Payment Terms: Schedule of payments, including interest rate and due dates
4. Default Provisions: Consequences of missed payments and remedies
5. HIPAA Compliance: Provisions ensuring compliance with patient privacy requirements
6. Governing Law: Specification of applicable state law and jurisdiction
7. Signature Block: Space for dated signatures of all parties
1. Collateral: Description of any assets securing the debt - used when secured payment is required
2. Insurance Coverage: Details of applicable insurance coverage - included when insurance may cover part of the debt
3. Acceleration Clause: Conditions under which full payment becomes immediately due - used for higher-risk arrangements
4. Late Payment Penalties: Specific penalties for late payments - included when additional late payment terms are desired
1. Schedule A - Itemized Medical Services: Detailed breakdown of medical services provided and their costs
2. Schedule B - Payment Schedule: Detailed payment timeline with amounts and due dates
3. Schedule C - Insurance Information: Details of insurance coverage and claims status if applicable
4. Schedule D - Truth in Lending Disclosures: Required federal disclosures regarding credit terms and costs
Lender
Principal Amount
Interest Rate
Default
Due Date
Maturity Date
Payment Schedule
Medical Services
Treatment Date
Late Payment
Late Payment Fee
Event of Default
Cure Period
Collateral
Guarantor
Healthcare Provider
Insurance Coverage
Outstanding Balance
Prepayment
Acceleration
Business Day
Notice
Governing Law
Jurisdiction
Protected Health Information
Collection Costs
Default Interest Rate
Payment Period
Remedies
Interest Rate
Default
Acceleration
Late Payment
Prepayment
Collection
Privacy
Confidentiality
Security
Insurance
Representations and Warranties
Notice
Amendment
Assignment
Severability
Governing Law
Dispute Resolution
Force Majeure
Indemnification
Waiver
Entire Agreement
Counterparts
Patient Rights
Healthcare Provider Rights
Collection Practices
Default Remedies
Information Protection
Service Description
Payment Schedule
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