Patient Payment Plan Authorization For Auto Pay Agreement - Katahdin Valley Health Center

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Katahdin Valley Health Center
Patient Payment Plan Authorization for Auto Pay Agreement
I, (please print) ____________________________________________________ understand I am entering into a payment plan
agreement with Katahdin Valley Health Center.
Starting _____/______/______, I wish to (Please check one below):
Mail/Drop off $_________ each Month/Week (circle one and complete Option 1 below)
Debit/credit $_________ each Month/Week (circle one and complete Option 2 below)
EFT checking $_________ each Month/Week (circle one and complete Option 3 below)
OPTION #1 - MAIL/DROP OFF PAYMENT PLAN
By placing my signature below, I am agreeing to the above payment arrangements of amount and timing. I further agree in the
event that I am unable to make a payment I will notify the billing department.
Date _____________
Signature ____________________________________
OPTION #2 - CREDIT/DEBIT CARD AUTO PAY OPTION
Check one -
Mastercard
Visa
Discover
American Express
(Card Number)
V-Code (3 - 4 digits on back of card)
Expiration Date
(Month & Year)
Name on Card
Address
City
State
ZIP
OPTION #3 - CHECK BY PHONE/CHECKING ACCOUNT DEBIT OPTION
Name(s) on Checks
Address
City
State
ZIP
9-Digit Routing Number
Checking Account Number
Name of Bank
By placing my signature below, I am agreeing to the above payment arrangements to be placed on auto-pay and debited beginning
the month and day indicated above. I futher agree in the event that funds are not available, I will be responsible for any charges
incurred as a result of an overdraft/returned item fee.
Date _____________
Signature ____________________________________

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