Authorization for Automatic Payment

"*" indicates required fields

Authorization for Automatic Payment

(Credit Card, Debit Card, or Bank Account Authorization)

Enrolling Member Name*

Name as it appears on credit/debit card or bank account*

Account Type*

Rounting Number*

Account Number*

Card Expiration Date*

Security Code*

Billing Address for Credit/Debit card*

Initiation fee to be charged*

Monthly membership amount to be charged or withdrawn each month*

Date of recurring monthly membership charge*

Email Address*

I hereby authorize WEST BEND FAMILY MEDICINE to charge the above referenced credit card or bank account automatically every month and apply those charges to the membership fees required for participation in the direct primary care membership offered through West Bend Family Medicine, and to any other charges I incur from services received that are not covered by the membership. I understand that I will remain responsible for recurring charges, additional late fees, and any other applicable charges if the withdrawal to the bank account I have listed above is denied for insufficient funds or the account otherwise becomes unavailable.

In the event I have selected to have automatic payments made from a bank account, I hereby authorize West Bend Family Medicine to initiate automatic withdrawals via electronic fund transfer as of the date of this agreement and as amended from time to time. I agree to indemnify the originating depository institution and any third-party service providers involved in processing entries made hereunder against all claims, demands, losses, liability, or expense including attorney’s fees and costs that result directly or indirectly from 1) a failure to follow the rules, 2) violation of law.

I understand it is my responsibility to notify West Bend Family Medicine of changes to my address, phone number, email address and other billing or contact information. An inability to collect membership fees due to incorrect or outdated billing information will result in the termination of my West Bend Family Medicine membership, including family members signed up under the membership.

Authorized Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.

You are filling up 2 out of 3 of the Direct Primary Care registration forms. After completing this forms, please fill up Electronic Transmission Disclosure and Acceptance.