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Request Medical Payment Plan Business Form Template


123 Main St., Apt. #5
Anytown, CA 95928
(555) 555-1212
danny@anyemail.com

November 8, 2008

Anytown Medical Center
345 Goodhealth Place
Anytown, CA 95928

To Whom It May Concern:

I am writing in response to the statement I received noting that I owe $135 for the services of Dr. Goodcare.

It is with great regret that I write to state that my current financial situation does not permit me to pay this amount in full by the due date.

I would like to request that a monthly payment schedule be arranged. I am in a position to remit $25 per month until the bill is settled.

Please let me know if this arrangement would be acceptable. I'll look forward to hearing from you and appreciate any flexibility you can offer.

Sincerely,

Danny Daniels








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