ACH Authorization

I hereby authorize CompleteCare, Inc., to initiate debits and/or credits to the bank account identified by me for payments due towards my healthcare related billing account(s), or when applicable, to apply electronic funds transfer credits to the same.

For accounting purposes, all electronic debits/credits will be reflected on the monthly bank statement that corresponds with the financial institution account of which I have provided information.

I understand and authorize all of the above as evidenced by my use of this payment option.