Patient Loyalty Builder Intake form
Authorization Agreement of Monthly Direct Deposit
When a patient enrolls in your in-house plan, the membership fee is collected through an online payment portal. We need the below financial information so we Careington (our licensed insurer) can pay you your distribution of the membership fee.
I (we) hereby authorize CAREINGTON INTERNATIONAL, to initiate credit and, if necessary, debit entries and adjustments for any credit entries in error to my (our) account, at the depository Financial Institution name above, and to credit or debit the same from such account. I (we) acknowledge that the authority will remain in effect until I have (or either of us) cancelled it in writing and that the origination of ACH transactions to my (our) account must comply with the provisions of U.S.law.
Note: Careington commissions are released once an agent's commission reaches a minimum of $25 and commissios will be paid on or around the 15th of the month for the prior month.