Easy Pay Authorization

PAYMENT SETUP

Secure Payment Authorization

Complete the information below to set up convenient electronic payment processing. Your banking details are transmitted securely and never stored on our servers.

Bank ABA Number (Customer's Routing Number) *

Bank Account Number (Customer's Account Number) *

Bank Account Type *

First Name *

Last Name *

Title *

Name of Organization *

Signature (Type your full name to sign electronically) *

Billing Contact Email *

Billing Contact Phone Number *

By signing this document, I authorize Adaptive Medical Partners to initiate either and electronic debit or create and process a demand draft against my bank account according to the terms outlined below. I acknowledge that the origination of ACH Transactions to my account must comply with provisioning of United States law. Starting on this day and subsequently debited at any time for the amount owed to Adaptive Medical Partners as detailed in approved invoices as outlined in your contract. These invoices will be sent via email. Approved invoice examples include monthly fees (billed on the 1st of every month), placement fees, marketing and travel expenses.

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This payment authorization is to remain in full force and effect until I notify Adaptive Medical Partners of its cancellation by sending a 30 day written notice per the original contract which allows both Adaptive Medical Partners and the receiving financial institution a reasonable opportunity to act upon it.

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Adaptive Medical Partners will provide the customer with a receipt of every invoice processed.

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I accept the terms and conditions.

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