Payment Authorization Form

$20.00

SKU: 2006 Categories: ,

Payment Authorization Form

The Payment Authorization Form grants {{Company}} permission to charge the signee’s credit/debit card or bank account for services, missed appointments, or other outstanding payments.

Key Points:

  • Authorization: The signee authorizes recurring charges to their chosen payment method.
  • Responsibility: The signee agrees to notify {{Company}} in writing of any changes to their account information or to terminate the authorization.
  • Payment Processing: The signee understands payments may be processed on the next business day if the scheduled date falls on a weekend or holiday.
  • ACH Transactions: For ACH payments, the signee acknowledges that funds may be withdrawn from their account as soon as the transaction date and accepts a $35 fee for each NSF return.
  • Legal Compliance: The signee confirms the transactions comply with U.S. law and will not dispute them with their bank/credit card company as long as they match this agreement.

By signing, the signee confirms they are an authorized user of the account and accepts responsibility for all charges.

Payment Authorization Form

The Payment Authorization Form grants {{Company}} permission to charge the signee’s credit/debit card or bank account for services, missed appointments, or other outstanding payments.

Key Points:

  • Authorization: The signee authorizes recurring charges to their chosen payment method.
  • Responsibility: The signee agrees to notify {{Company}} in writing of any changes to their account information or to terminate the authorization.
  • Payment Processing: The signee understands payments may be processed on the next business day if the scheduled date falls on a weekend or holiday.
  • ACH Transactions: For ACH payments, the signee acknowledges that funds may be withdrawn from their account as soon as the transaction date and accepts a $35 fee for each NSF return.
  • Legal Compliance: The signee confirms the transactions comply with U.S. law and will not dispute them with their bank/credit card company as long as they match this agreement.

By signing, the signee confirms they are an authorized user of the account and accepts responsibility for all charges.