CONSUMER ACH PAYMENT AUTHORIZATION FORM

Jack L. Koch Jr., M.D., PLLC
1507 16th Avenue S.
Nashville, TN 37212
(615) 515-7775

I (we) authorize Jack L. Koch Jr., M.D., PLLC to electronically debit my (our) account (And, if necessary, electronically credit my (our) account to correct erroneous debits) as follows:

Bank Account Type*

Personal Checking AccountPersonal Savings Account

I authorize electronic ACH debits / credits to the depository financial institution named below (“DEPOSITORY”). I (we) agree that ACH transactions I (we) authorize comply with all applicable law.

Name on Account*

Patient Name (if different)

First NameLast Name

Bank Name*

Bank Account Number*

Bank Routing Number*

Bank City/State*

This Bank Account is Enabled for ACH Transactions*

YesNo

Dates and/or Frequency of Debits*

One timeRecurringFollowing provision of treatment services (most common option)

Maximum Dollar Amount Authorized: $500

I (we) understand that this authorization will remain in full force and effect until I (we) notify Jack L. Koch Jr., M.D., PLLC in writing that I (we) wish to revoke this authorization. I (we) understand that Jack L. Koch Jr., M.D., PLLC requires at least 15 days prior notice in order to cancel this authorization.

I certify that I am an authorized signer for the account indicated above and that I have the authority to authorize this/these transactions. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date, and that I will have limited time to report and dispute errors. In the case the transaction is returned for Non Sufficient Funds (NSF) I understand that Jack L. Koch Jr., M.D., PLLC may at its discretion attempt to process the charge again within 30 days, and agrees to an additional $10.00 charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. I have certified that the above bank account is enabled for ACH transactions, and agree to reimburse Jack L. Koch Jr., M.D., PLLC all penalties and fees incurred as a result of my bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions. Both parties agree to be bound by NACHA Operating Rules as they pertain to this transaction. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this transaction with my bank provided the transaction corresponds to the terms indicated in this authorization form.

I agree to the terms and conditions described above.*

Yes

Name*

PrefixFirst NameMiddle NameLast NameSuffix

Date*

Date

Signature*