Spenddown Payment Plan Request Client Contact InformationName(Required) First Name Last Name Date of Birth(Required) Phone Number(Required)Email Address(Required) Billing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Ongoing Monthly Payment Amount(Required)Required Minimum Monthly Payment Amount of $100.00 Monthly Payment Obligation(Required)I understand that in order to maintain active services, I am required to pay the minimum monthly payment of $100.00, and any newly accrued monthly spenddown balance in full each month by the designated due date. Services will not remain active if both payment obligations are not met in full each month. I agreeMissed Payments(Required)If I fail to submit a payment before the due date, my payment plan may be terminated. This agreement does not waive the client’s responsibility for the full spenddown amount. I agreeInitial Payment Requirement(Required)Your payment plan request will be pending review until your first payment has been made. Requests without an initial payment will not be approved. You will be redirected to the payment page upon submission of this form. I agreeAcknowledgment & Signature(Required)By signing below, the client/guardian acknowledges that they agree to the Terms & Conditions of this Payment Plan. The Spenddown amount is accurate based on current Medicaid eligibility and service authorization. They understand this is their financial responsibility. This agreement does not alter Medicaid rules or eligibility requirements.CAPTCHA
