ACH AUTHORIZATION AGREEMENT As a condition of receiving treatment at this office, all fees are due at the time of service. We understand that you may not know how to file your insurance claim. We will file your insurance claim on your behalf as accurately as possible, based on the information that you have provided. PLEASE NOTE: Our relationship is with YOU—not your insurance company. Therefore, all charges are ultimately YOUR responsibility, regardless of your insurance status. After 90 days, if your insurance company has not reimbursed our offices, you agree to accept responsibility for rending payment. All information that you have provided on this form will remain strictly confidential and used only for the purposes stated in this agreement. Please make a credit card charge/direct debit from my account for the balance of charges not paid by insurance within 90 days and not to exceed*Please make recurring charges for ongoing treatments in the amount of*every*PATIENT INFORMATION:Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number:*Select Payment Type Desired* Bank Account Credit/Debit Card CHECKING/SAVINGSBank Name:*Name on Account:*Address on Account:*ABA Routing Number:*Account Number:*CREDIT CARD/DEBIT CARDName on Card:Card Number:*Expiration Date* Put in last day of month of the expiration.CVV/CVC*Name of Card Company*Signature*Date* Please contact our office by phone at 970-221-9451.