Credit Card Recurring Authorization Form
Patient Assistance Advocacy Membership
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Birth Date
*
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Year
Address
*
Street Address
Apt #
City
State / Province
Postal / Zip Code
Choose Your Monthly Advocacy Membership
*
$60.00 - Individual Advocacy Membership (3% surcharge will be applied on each credit card transaction to a total of $61.80)
$100.00 - Family Advocacy Membership (3% surcharge will be applied on each credit card transaction to a total of $103.00)
Type of Credit Card (We do not accept AMEX)
*
VISA
MASTERCARD
DISCOVERY
Requirements for Patient Assistance
*
MUST BE UNINSURED
LOW INCOME UNDER THE 300% POVERTY LEVEL (FPL)
MUST HAVE AN ACTIVE CHECKING ACCOUNT
PROVIDE PROOF OF INCOME (W2, PAY STUBS, UNEMPLOYMENT, BANK STATEMENTS, etc)
LEGAL RESIDENT/CITIZEN
PROOF OF ADDRESS (ANY UTILITY BILL)
PROVIDE A FORM OF ID
APPLICANT CAN NOT HAVE STOCKS, TRUST FUNDS, MULTIPLE PROPERTIES, or MORE THAN $3000.00 IN SAVINGS IN THE BANK.
I understand LHBG-INC is NOT A MEDICAL INSURANCE company NOR DISPENSE RX MEDICATIONS.
I understand LHBG-INC employees are ONLY advocates to locate medical care, Rx cost assistance, medical equipment, and other financial assistance that is available to the uninsured and low-income individuals that qualify.
Terms & Conditons
*
I authorize LENNY HEALTH BENEFITS GROUP, INC (LHBG-INC) to initiate either an electronic debit or to create and process a demand draft against my CREDIT CARD according to the terms outlined above. I acknowledge that the origination of CREDIT CARD transactions to my account must comply with the provisioning of United States law. Terms of Billing Starting on the date I sign this form and each month thereafter. This payment authorization is to remain in full force and effect until I notify LENNY HEALTH BENEFITS GROUP, INC of its cancellation by sending a written notice 10 days prior to my due date via email to ADVOCATES@LHBG-INC.COM. I understand advocacy membership services are NON-REFUNDABLE once service(s) are rendered. By e-singing below, I understand and consent to the term of billing.
Date
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Day
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Date
Signature
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