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...Monthly payment agreement contract patient name date terms i understand that am entering into a between myself and reliant inc further must sign return this for it to be executed by signing below st will held responsible consent making my the of each month on account aware any late result in fee being assessed or sent collection agency options choose one o credit card authorization recommended processed first day until is paid full billing address cc type mastercard visa discover amex number expiration security code cvv make every if you option your responsibility please mail check information our company headquarters at summit grv brandon ms online website www reliantpt com minimum mo balances over other amount desire pay more than signature signed form pt grove email info phone fax...