Date:
Zip
Patient Signature:
Financial Svcs Director or Designee:
Date
due and payable to the City of Rio Rancho by the 15th day of each month beginning as of the
date first written above and continuing until the balance is paid in full (the last payment may be
less than $50.00). I understand that should I fail to make a payment within ten days of its due
date, this payment plan will terminate and I will immediately be responsible for paying any
remaining balance in full. The total balance must be paid in full within one year of the date first
Please return this completed and signed form to: Attn: Steve Perkins, Ambulance Billing, 3200
Civic Center Circle NE, Rio Rancho, NM 87144.
(or legally authorized)
Accepted by:
Steven Perkins, Supervisor EMS Billing Date
By signing below, I hereby acknowledge that I have read and agree to the terms of this
Agreement.
Street
For the patient number referenced above, my outstanding balance owed to the City of Rio Rancho
is:
Section II - Payment Information
City/State
Phone #:
City of Rio Rancho
Department of Finance - Ambulance Billing
Payment Plan Agreement
Please complete all the information on this form as completely and accurately as possible by typing or using blue or
black ink. Please contact us at (505) 891-5021 with any questions.
Last Name First Name
Section I - Patient Information
Patient Name:
Date
Acct #
E-Mail:
(minimum $50.00)
I hereby agree to submit monthly payments to the City in the amount of:
Address:
v10.09.20
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signature
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