Automatic Payment Form

Automatic Payment Plan Authorization Form

BillMed Management LLC is pleased to offer an Automatic Payment Plan to simplify the payments of your Invoices. With the Automatic Payment Plan, your payment is automatically deducted from your Checking Account on your due date. You have one less check to write and we receive your payment on time.

I hereby authorize BillMed Management LLC to initiate recurring electronic debit entries (Auto-Pay) from my bank account identified below, and if necessary, to initiate credit entries to correct erroneous debits, in accordance with rules of the National Automated Clearing House Association (NACHA) and applicable federal and state laws. 

This authorization permits ongoing, recurring  debits  corresponding to the amounts owed, due, or contractually authorized.

MM slash DD slash YYYY

This authorization will remain in full force and effect until I notify the Company to cancel my Automatic Payment, a minimum of three (3) business days before the date of withdrawal, in writing via email or standard mail.

Returned or rejected payments may result in applicable fees, as permitted by law. Revocation of this authorization does not eliminate my obligation to pay amounts lawfully owed.

Authorization & Consent

By signing below, I certify that:

  • ⋅ I am an authorized signer on the bank account listed above
  • ⋅ I consent to recurring ACH debits as described 

THERE IS ABSOLUTELY NO EXTRA COST TO YOU!

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