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MIDLAND EXTENDED PAYMENT PLAN

MEDICAL LINE OF CREDIT AGREEMENT TERMS AND DISCLOSURE STATEMENT

Administered at the direction of Midland Professional Services, Inc. “Midland”

THIS AGREEMENT is between the hospital, clinic, physician or other medical provider (referred to collectively as “Medical Provider”) and patient(s) and/or account guarantor(s) (referred to collectively as “Patient”) and these terms and the specific terms identified on the Terms of Acceptance Form shall both be considered collectively as one agreement which shall be effective upon return of your verbal agreement by phone or signed Terms of Acceptance Form as follows:

1. Line of Credit. Fees for medical goods and services provided by the Medical Provider currently owed by Patient shall be paid through this Medical Line of Credit as long as this account is not canceled and so long as it is not delinquent.

2. Promise to Pay. Patient promises to pay through monthly payments all charges assigned to this account for medical goods and services financed hereunder, the Finance Charge, the Annual Fee, and the additional charges as provided herein. Unless modified, the Minimum Monthly Payment shall be as agreed or the total amount owed, whichever is less. The account balance may be prepaid at any time without penalty. This Agreement may not be assigned except by Medical Provider who may do so without advance notice or consent. All parties signing this agreement will be jointly and severally obligated for all amounts charged to the Medical Line of Credit created by this agreement.

3. Administration and Notices: This account will be administered by Midland Professional Services, Inc. “Midland”. After receipt of the signed acceptance of the terms of this agreement, all inquiries regarding payments or balances should be directed to Midland at the address indicated on this site or your monthly statement or Toll Free 1-800-595-7868.

4. Additional charges and amendment of the minimum payment amount: Fees for additional medical goods and services provided by the Medical Provider to Patient or certain related accounts may be added to this account if it is current and both Medical Provider AND any individual signing this agreement consents either in writing or orally. Any additions will be reflected on the next regular statement. Medical Provider reserves the right to review and establish new minimum payment requirements if new charges are added to the outstanding balance.

5. Application of payments: Payments will be applied first to accrued Finance Charge; second to other charges; and then to the unpaid balance remaining on the account.

6. Closure. Either Patient or Medical Provider (through its Administrator identified above) may close this account to additional charges for goods and services through written notice to the other party. If this is a joint account, any one person signing this agreement may close this account to future charges. Even if this account is closed, payments must continue according to the terms stated in this agreement.

7. Default. Default occurs under this agreement if on the billing date the minimum amount due on the account exceeds two times the Minimum Monthly Payment. Written notice of default will be Emailed or mailed first-class mail, postage prepaid, to Patient at the address on file and shall be effective upon mailing. If the default is not remedied as specified in the written notice of default, Medical Provider may cancel this agreement, causing the entire balance to become due and entitling Medical Provider to refer the account to a professional collection agency or law firm for appropriate action. Further, absent timely payment, this account may be closed to further activity.

8. Patient address: All notices related to this agreement will be sent to you at the address identified on the signed terms acceptance form unless Patient notifies Midland in writing of a change of address, in which case the new address shall be effective five days after receipt by Midland.

CREDIT LINE DISCLOSURE STATEMENT

Balance computation method: The Finance Charge on this account will be computed by applying the periodic rate to the Average Daily Balance of this account (including fees for additional services added to the account). The Average Daily Balance is determined by taking the beginning balance of this account each day, adding any fees for additional medical goods and services charged to the account by mutual agreement, and subtracting any payments or credits. This gives the daily balance. All the daily balances for the billing cycle are then added, and the total is divided by the number of days in the billing cycle. This gives the Average Daily Balance.

Computation of Periodic Rate and FINANCE CHARGE: The Finance Charge is computed as follows. The Annual Percentage Rate is divided by 365 to determine the daily percentage rate. The number of days in the billing cycle is multiplied by the daily percentage rate to determine the Periodic Rate. The Periodic Rate is multiplied by the Average Daily Balance to determine the Finance Charge.

When Finance Charges begin to accrue: The Finance Charge will begin to accrue as of the date your account is activated by Midland, after receipt of a signed Terms Acceptance Form, unless the account is paid in full within any “Grace Period” identified in the Terms Acceptance Form, if any, following your first billing statement from Midland.

Annual Fee: Patient agrees the account will be charged an annual fee of $15.00 upon activation and each anniversary following account activation.

Returned check fee: If any check received for payment on this account is returned for non-payment, the account will be assessed a returned check charge of $10.00 and any other actual fees directly related to any insufficient payment.

PATIENT BILLING RIGHTS–KEEP THIS NOTICE FOR FUTURE USE

This notice contains important information about rights and our responsibilities under the Fair Credit Billing Act.

If the bill is believed to be wrong or if more information is needed about a transaction on the bill, write a letter (on a separate sheet) to Midland Professional Services, Inc. Write as soon as possible. Midland must receive notice no later than 60 days after the first bill on which the error or problem appeared was sent. Midland may be contacted by telephone, but doing so will not preserve these rights. In the letter, provide the following information: 1) your name and the account number; 2) the dollar amount of the suspected error; 3) a description of the error and explain, if possible, why the error is believed to exist; and 4) if more information is needed, describe the item. If Midland is authorized to pay your account automatically from your savings or checking account, payment may be stopped on any specific amount believed to be wrong. To stop the payment your letter must reach Midland three business days before the automatic payment is scheduled to occur.

Patients have certain rights and responsibilities once Midland receives this written notice. Midland must acknowledge your letter within 30 days, unless the error has been corrected by then. Within 90 days, Midland must either correct the error or explain why they believe the bill was correct. After Midland acknowledges receipt of the letter, Midland cannot try to collect any amount questioned, or report the same to third parties other than Medical Provider. Midland can continue to bill the Patient for the amount in question, including Finance Charges, and Midland can apply any unpaid amount against Patient’s credit limit. Patients do not have to pay any questioned amount while Midland is investigating, but Patient is still obligated to pay the parts of the bill that are not in question. If Midland finds that a mistake has been made on the bill, no Finance Charges will have to be made related to any questioned amounts. If a mistake was not made, Patient may have to pay Finance Charges, and Patient will have to make up any missed payments on the questioned amount. In either case, Midland will send a statement of the amount owed and the date that it is due. If Patient fails to pay the amount that is believed to be due, Midland may report the account to the Medical Provider. However, Midland’s explanation does not satisfy Patient and Patient writes to Midland within 10 days telling Midland that Patient still refuses to pay; Midland must tell anyone Midland reports to that Patient has a question about the bill. And, Midland must tell Patient the name of anyone Midland reported the information to. Midland must tell anyone they report Patient to that the matter has been settled when it finally is. If Midland doesn’t follow these rules, the first $50 of the questioned amount can’t be collected, even if the bill is correct.