ACH Authorization Form
List All Patients to Include in this Authorization
*
Email
*
example@example.com
Name(s) on Bank Account
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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
Fee Schedule
*
Annually (One Payment)
Bi-Annually (Two Payments)
Quarterly (Four Payments)
Monthly (Twelve Payments)
Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: