Billing & Agreements

Authorization for Direct Payment via ACH

Authorizes electronic debits for the deposit and bi-weekly invoices.

About 4 minutesClients & responsible parties

Paper form for your protection

For your protection, bank account and routing numbers are never collected on our website. Please print this form, complete it by hand, attach a voided check, and return it to our office.

Account holder

Client NameResponsible Party Name

I hereby authorize Golden Grace Health Care LLC to electronically debit my account (and if necessary, electronically credit my account to correct erroneous debits) at the financial institution(s) indicated below:

Terms of Billing

I authorize the initial deposit of ($) to be debited from this accountStarting on (mm/dd/yyyy) and subsequently debited on every other week, I authorize for the amount owed to Provider as detailed in Invoices provided to me to be debited.

Bank details

Bank NameBank Routing NumberAccount NumberType of AccountAccount Holder NameIndicate Specific Amount ORIndicate Percentage

A voided check must be attached for processing to be complete.

Signature

Client or Responsible Party Name

Client or Responsible Party Signature and Date *

By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.