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EASY PAY AUTHORIZATION FORM
Please complete all fields to activate electronic funds transfer
Terms and Conditions
I accept the terms and conditions.
By signing this document, I authorize Adaptive Medical Partners to initiate either an 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 the 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.
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 on it.
Adaptive Medical Partners will provide the customer with a receipt for every invoice processed.
Bank ABA Number (Customer's Routing Number)
Bank Account Number (Customer's Account Number)
Bank Account Type (Checking/Savings/Other)
First and Last Name
Name of Organization
Billing Contact Email
This field is for validation purposes and should be left unchanged.
Adaptive Medical Partners
3229 Premier Drive, Suite 200
Irving, TX 75063