Orange County NC Website
Browse       Search
DocuSign Envelope ID:OE76022E-EB24-4BC8-9CBE-2BA3FA1CCA27 <br /> Patagoidallealth Sales Agreement <br /> ACH PREAUTHORIZED PAYMENTS (DEBITS) <br /> Starting from date ( / / /201 a 1 hereby authorize Patagonia Health Inc to initiate debit entries or <br /> such adjusting entries, either debit or credit which are necessary for corrections, to my Checking X Or <br /> Savings account indicated below and the financial institution named below to credit(or debit) <br /> the same to such account. <br /> FINANCIAL INSTITUTION NAME CITY, STATE <br /> TRANSIUROUTING NUMBER ACCOUNTNUMBER <br /> I understand that this ACH authorization will be in effect until I notify my financial institution in writing that I no longer <br /> desire ACH,allowing it reasonable time to act on my notification. I also understand that if corrections in the debit amount <br /> are necessary, it may involve an adjustment(credit or debit)to my account. <br /> I have the right to stop payment of a debit entry by notifying my financial institution before the account is charged. If an <br /> erroneous debit entry is charged against my account,I have the right to have the amount of the entry credited to my account <br /> by my financial institution. I agree to give my financial institution a written notice identifying the entry,stating that it is in <br /> error,and requesting credit back to my account. I will provide this written notice within 45 days after posting. <br /> NAME <br /> PRACTICE NAME <br /> SIGNATURE DATE <br /> Confidential Page 9 <br />