Payment plan agreement for an unpaid ride balance: amounts, dates, and what a missed payment means
Overview
A payment plan agreement puts an unpaid ride balance in writing: the total owed, each installment and its date, how it will be paid, what happens after a missed payment, and the right to pay early. Keep it to four installments or fewer with no interest, and get a signed authorization before debiting a bank account.
On this page
How to use this agreement
This is the written plan for a private-pay balance a rider or family cannot pay in one payment. The collection guide covers when to offer a plan and the steps around it, and this page is the document you sign.
- Offer it after the reminders, before an agency. Send the past-due letters first, so the family has seen the balance in writing.
- Attach an itemized statement. List every ride in the balance with its date and charge, in the layout of the statement of account.
- Keep it to four installments or fewer, with no interest. The collection guide explains the federal credit rule behind that limit. The rule leaves a down payment out of the count, and the form’s four payment lines, a down payment and three installments, stay within four even if it were counted.
- Treat card and bank consent as separate. A saved card still needs the signed credit card authorization form. This agreement does not replace it.
- Get the family’s consent for payment texts. The health care exemption described in the TCPA guide leaves out billing and debt-collection content, so write the phone number or email the family chose into Part 3.
- Never use it for a covered Medicaid ride. See charging Medicaid patients for transportation for the narrow cases where a charge is allowed.
- Sign it once and hand over a copy that day. Keep the signed original with the trip records for the rides it covers.
The agreement
Copy the text below onto your letterhead. Words in brackets are yours to fill in.
Part 1: The balance
This agreement is between [company legal name] and [name of the person who owes].
You owe $____ for the rides listed on the attached statement dated ____ (rides from ____ to ____). That is the full amount owed on ____.
We add no interest and no fees to this amount while you follow this plan.
Part 2: The payments
| Payment | Due date | Amount | How you will pay |
|---|---|---|---|
| When you sign (optional) | $ | ||
| Payment 1 | $ | ||
| Payment 2 | $ | ||
| Payment 3 | $ | ||
| Total (matches Part 1) | $ |
Part 3: How you will pay
You choose one way, and you can change it at any time by telling us. You never have to choose automatic bank payments.
☐ Pay link. We send a link to ____ (text number or email) ____ days before each due date.
☐ Card on file. We charge the card ending ____ on each due date. You signed our card authorization form on ____.
☐ Check. Mail it to ____ so it arrives by the due date.
☐ Automatic bank payment. We take each payment from the bank account ending ____ on its due date, after you sign the bank authorization in Part 7. You can stop a payment by telling your bank at least 3 business days before the due date. If a payment will ever be a different amount, we will send you written notice of the amount and date at least 10 days before.
Part 4: If a payment is missed
If we have not received a payment ____ days after its due date, we will call or text you and send you a written notice.
If a card payment is declined, we will tell you in writing, and you will have at least 7 days to pay another way.
After the notice, you will have ____ days to pay the missed payment or ask us to change the plan. If you do neither, the rest of the balance becomes due, and we may use our usual steps to collect it.
A missed payment does not add interest or a fee to what you owe.
If your signed rate sheet or agreement allows a late fee, replace the last line with the flat amount and the number of days late. Leave the line as written when it does not.
Part 5: Paying early and making changes
You can pay more than the amount due, or pay the whole balance, at any time. There is no penalty. Extra money goes to the next payments due.
This plan changes only when both of us agree in writing. A text or email reply of “agree” from each of us counts.
Part 6: New rides
Rides after the date of this agreement are not part of it. They are paid ____ (for example, by card when you book).
Part 7: Signatures
I agree that I owe the balance in Part 1 and will pay it as shown in Part 2. I received a copy of this agreement.
Name: ____ Signature: ____ Date: ____
Company: ____ Signature: ____ Date: ____
Copy given on ____ by ☐ hand ☐ email ☐ text link.
Add this only when the family chose automatic bank payments:
Bank authorization. I allow [company legal name] to take the payments in Part 2 from my bank account ending ____ on the due dates. I can stop a payment by telling my bank at least 3 business days before the due date. I received a copy of this authorization.
Name: ____ Signature: ____ Date: ____
An example, with made-up numbers
A rider owes $540.00 for six one-way rides in August at $90.00 each. His daughter, who accepted the charges when she booked, signs on October 15 and chooses pay links. She pays $90.00 at signing, then $150.00 on November 15, December 15, and January 15.
| Payment | Due date | Amount | How you will pay |
|---|---|---|---|
| At signing | Oct 15 | $90.00 | Pay link |
| Payment 1 | Nov 15 | $150.00 | Pay link |
| Payment 2 | Dec 15 | $150.00 | Pay link |
| Payment 3 | Jan 15 | $150.00 | Pay link |
| Total | $540.00 |
The company texts the link three days before each due date. Part 4 says seven days late brings a call or text and a written notice, and ten more days to pay or ask for a change before the rest of the balance becomes due. The plan has three installments and a down payment, no interest, and no card or bank consent to collect, because she is paying by link each time.
Where each clause comes from
Most clauses in the form follow a rule you can look up, and the table names it. Lines that apply only to bank debit or stored cards can be dropped from a plan that uses neither.
| Clause in the agreement | Rule behind it |
|---|---|
| Four installments or fewer, no interest | 12 CFR 1026.2(a)(17), the definition of a creditor |
| Bank payment is a choice, never required | 12 CFR 1005.10(e)(1) |
| Signed bank authorization and a copy | 12 CFR 1005.10(b) |
| Stop a payment 3 business days ahead | 12 CFR 1005.10(c)(1) |
| Written notice 10 days before a changed amount | 12 CFR 1005.10(d)(1) |
| Written consent to the card terms, no interest, a flat late fee only | Visa Core Rules, Tables 5-20 and 5-21 |
| Written notice and 7 days after a declined card | Visa Core Rules, Table 5-22 |
Visa’s rules reach the merchant through its card processor. Read your processor agreement for the rules of other card brands before you save a card for a plan.
Writing it so a family can follow it
The people signing are not lawyers, so plain wording gets a plan understood, signed, and followed.
- Say “missed payment,” not “default.” Say “the rest of what you owe becomes due,” not “acceleration.”
- Use calendar dates. “November 15” is clearer than “30 days after signing.”
- Put the total and the schedule in the first half of the page. The table in Part 2 is the part a family keeps.
- Name one person to call. Print a phone number answered during the day.
Payment plans in HealthRide
In HealthRide, each installment can be collected by card, with a pay link or a saved card, as it comes due. A check or cash payment is recorded on the same ledger, matched to the trip it pays, and refunds are recorded there too. See payments and invoicing.
Frequently asked questions
- Can automatic bank withdrawals be required for the plan?
- Treat the answer as no. The statute says no person may condition the extension of credit to a consumer on repayment by preauthorized electronic fund transfers (15 U.S.C. 1693k), Regulation E repeats it (12 CFR 1005.10(e)(1)), and the CFPB's comment adds that creditors may not require repayment of loans by electronic means on a preauthorized, recurring basis. Regulation E defines credit as a right granted by a financial institution (12 CFR 1005.2(f)), so it is not clear the rule reaches a ride company's own plan. Offer bank debit as one choice and always leave a pay link, a card, or a mailed check as another.
- What must a family sign before I take money from their bank account?
- A writing signed or similarly authenticated by the consumer, and you must give them a copy (12 CFR 1005.10(b)). The consumer can stop a debit by telling their bank, orally or in writing, at least three business days before the scheduled date (1005.10(c)). When a debit will differ in amount from the last one or from the amount authorized, the payee has to send written notice stating the amount and date no later than 10 days before it (1005.10(d)). Part 3 and the bank authorization in Part 7 of the template carry all three.
- Can I charge interest or a late fee on a payment plan?
- The template charges neither. For payments taken on a stored card, Visa's rules bar finance charges, interest, and imputed interest, and any late fee on a partial payment must be a flat fee applied only as a late payment penalty (Visa Core Rules, 18 April 2026, Tables 5-20 and 5-21). Interest outside cards depends on your state's limits, and a plan with a finance charge can make a company a creditor under the federal truth-in-lending rules. Add a fee only when your signed rate sheet already allows it.
- What if a card payment on the plan is declined?
- Send the cardholder a written notice and allow at least 7 calendar days to pay by another route. That is Visa's rule when a payment the merchant starts on a stored credential is declined. Part 4 of the template puts the notice and the 7 days into the agreement, so the family has read the rule before it ever applies.
- Does signing a payment plan restart the statute of limitations?
- It may. The CFPB says that making a partial payment or acknowledging that you owe an old debt, even after the limit has passed, may restart the time period, and that most states set limits between three and six years. Whether it does depends on your state, so ask counsel before counting on a plan to revive a balance near its limit. Date the agreement and record every payment with its date.
- Who should sign the plan?
- The person who accepted the ride charges, or who takes over the balance and says so in writing. Someone who only made the booking has not necessarily agreed to owe the charges. Get the person who will pay to accept the total and the schedule in writing before the first installment, as the collection guide advises.
- Can a Medicaid rider be put on a payment plan?
- Not for a covered ride. A Medicaid provider accepts the state plan's payment, plus any cost sharing the plan charges the member, as full payment (42 CFR 447.15), so a covered ride leaves no balance to schedule. A plan fits only rides that were private pay, or a rider's own copay.
