ACH Draft Authorization Form
Services
Invoice #
*
list all if paying multiple
Patient Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name(s) on Bank Account
*
Bank Name
*
Routing Number
*
must be 9 numbers - no spaces
Account Number
*
must be 9-12 numbers - no spaces
Type of Bank Account
*
Personal Checking
Personal Savings
Business Checking
Business Savings
Signature
*
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: