ACH Authorization
Please complete when submitting first case.
Name of Practice
*
Name of Doctor
*
Prefix
First Name
Last Name
Suffix
Email Address for Confirmation
*
example@example.com
Customer Number (if known)
Should we keep this information on file or is this a ONE TIME CHARGE?
*
Please keep this information securely on file for future billing purposes.
Please charge my account today and keep this information securely on file for future billing purposes.
This is a ONE TIME CHARGE, do not keep this information on file
For ACH information kept securely on file:
*
Automatically run payment each month
Wait for practice approval to run payment each month
NA - Don't keep this payment information on file
Financial Information
*
Name of Financial Institution
*
Routing Number
In order to keep your information secure, we will CALL your business for the actual account number. We will contact you within one full business day of submitting this information, or you can contact us with the details.
I understand the account number will not be recorded on this form; it will be given over the phone. Please call the above practice for the information ASAP.
I understand the account number will not be recorded on this form; it will be given over the phone. I will call Cottonwood Labs at (801) 904-2006 upon completion of this form, to relay this information.
If we are charging your account today, please indicate the amount. If we are not charging your account today, please use 0.
*
Todays Amount
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
*
Submit
Submit
Should be Empty: