The Counseling Center of New England

One Main Street * Nashua, NH 03064 * (603) 883-0005

8 Auburn Street * Nashua, NH 03064 * (603) 883-0005

15 Trafalgar Square * Nashua, NH 03063 * (603) 883-0005

148 Coolidge Avenue * Manchester, NH 03102 * (603) 627-3111

294 D.W. Highway * Merrimack, NH 03054 * (603) 883-0005

77 Gilcreast Rd * Suite 3000 * Londonderry, NH 03053 * (603) 432-3033

45 Main Street * Peterborough, NH 03458 * (603) 924-3331
414 State Street * Unit 2 * Portsmouth, NH 03801 * (603) 334-2533

24 Front Street * Suite 100 * Exeter, NH 03833 * (603) 778-2005

16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222

53 Baxter Boulevard * Portland, ME 04103 * (603) 883-0005

61 NH Route 27, Unit 10 * Raymond, NH 03077 * (603) 689-7602

319 Whittier Highway * Suite 8 * Center Harbor, NH 03326 * (603) 546-6178

Fax all locations: 603-883-0007

Long Term Payment Agreement Request Form

Please note the following criteria must be met in determining an acceptable payment plan:

1.An initial good faith payment is due upon the signing of a payment plan in miminum amounts as follows: If your balance is up to $200, a minimum of half is required; if balance is over $200 a minimum of $100 is required now

2. If balance is $200 or less, payment must be completed in two month; if $200-$400 payment must be completed in 3 months; if over $400 it must be completed in 4 months.

3. If you are continuing in care, payments on outstanding balances must be in addition to remaining current on ALL ongoing costs of future care (i.e., payment for new services are due in full at the time of each service, and cannot be added to the existing outstanding debt on your account);

4. If you cannot complete payment per the criteria above, please schedule yourself into our online billing department schedule to speak with someone regarding a payment plan

Schedule an Appointment to Talk to Billing

Based upon the above criteria, please complete the following:

Today's Date *

Your Account Number(s):

Your Name: *

Patient name(s): *

Total Balance Due: *

Initial Good Faith Payment of: $ *

Method of Payment: *

Mailing or Delivering Check

Credit/Debit Card Payment Below

Regular Payment Plan Due on the 15th of Each Month:

Monthly: $

Method of Payment:

Mailing or Delivering Check

Use My Credit/Debit Card Below to Process Installments

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

3 digit security code (4 digit for Amex) *

Security codes are

found on the back

of the card or front

of the American Express

Additional information or intructions pertaining to payments or use of credit card.

In addition to my current payment above, I would like to leave my Credit Card information on file for future payments.

Please check any/all requests for future use of your credit card

Future Co-Pays and Balances Due - if not otherwise paid for in person at the time of your visit *
~~By selecting 'Yes' you are agreeing to all future co-pays and balances being charged to this credit card.~~ *

Yes

* If yes and you have submitted an FSA or HRA card, please also consider submitting a regular credit or debit card to cover when your FSA or HRA is depleted.

Charges for medication refills requested by phone

Yes

* If yes and you have submitted an FSA or HRA card, please also submit a regular credit or debit card for non-insurance billable services

Long Term Payments per Payment Plans, if applicable

Yes

Educational Liaison Services

Yes

* If yes and you have submitted an FSA or HRA card, please also submita regular credit or debit card for non-insurance billable services

Testing Co-Insurances

Yes

Non-Covered Charges for Educational Testing or Comprehensive Report Writing.

Yes

* If yes and you have submitted an FSA or HRA card, please also submit a regular credit or debit card for non-insurance billable services

Patient Signature: *

Date: * +

I understand that my typed name above shall have the same legal and binding authority as my handwritten signature.

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