Healthcare ACH Agreement

HEALTHCARE ACH AGREEMENT

This Automated Clearing House (ACH) Payment Authorization Agreement ("Agreement") is entered into between Provider Name: and Patient Name: . By signing below, Patient authorizes Provider to initiate electronic debit entries to the bank account designated below for payment of healthcare services and related charges in accordance with the terms set forth herein.

Patient Information

Insurance Information

Medical Summary (Optional)

Bank Account Information (ACH)

Payment Authorization and Terms

By signing this Agreement, Patient authorizes Provider to initiate ACH debit entries to the account designated above for the payment of services, co-payments, deductibles, installments, and any outstanding balances arising from services rendered by Provider. This authorization is for:

Patient represents and warrants that the account information provided is complete and accurate and that Patient is an owner or authorized signer on the account. Patient authorizes Provider to debit the account for the amounts indicated, and to adjust subsequent entries for any erroneous debits made in good faith.

Revocation, Cancellation, Returned Items

This authorization will remain in effect until revoked by Patient in writing. Patient must notify Provider at least 15 days prior to the next scheduled debit to allow Provider and the financial institution reasonable time to act on the revocation. Provider reserves the right to terminate ACH processing if debits are returned for insufficient funds or closed accounts.

If any ACH debit is returned unpaid, Patient agrees to pay a returned item fee and any costs reasonably incurred by Provider to collect the unpaid amount, including collection costs and attorneys' fees where permitted by law.

Representations, Liability and Indemnity

Patient acknowledges that Provider will process debits in accordance with NACHA rules and applicable law. Provider's liability for errors in ACH processing is limited to correction of the erroneous entry and, where applicable, reimbursement of fees charged by Patient's financial institution. Patient releases Provider from any liability for consequential damages resulting from ACH processing except as provided by law. Patient agrees to indemnify and hold Provider harmless from any claims arising from incorrect account information provided by Patient or unauthorized use of Patient's account.

Privacy and Electronic Communications

Provider will use the account information solely for purposes of initiating ACH transactions authorized herein and in accordance with Provider's privacy policies. By executing this Agreement Patient consents to electronic notification of debits and receipts unless Patient requests paper notification in writing. Patient acknowledges the right to receive a written copy of this authorization upon request.

Governing Law; Miscellaneous

This Agreement shall be governed by and construed in accordance with the laws of the state in which Provider maintains its principal place of business, without regard to conflict of law principles. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. Headings are for convenience only and do not affect interpretation.

Affirmations

By signing below, Patient affirms that they have read this Agreement in its entirety, that they have the authority to execute this authorization for the bank account specified, and that they consent to electronic debits as described. Patient understands they may revoke this authorization by providing written notice to Provider as specified above.

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