One-Time Payment Form

One-time-Payment Authorization Form
I hereby authorize BILLMED Management LLC to initiate a one-time electronic debit from my Bank Account identified below, and if necessary, to initiate a credit to correct erroneous debit, in accordance with the rules of the National Automated Clearing House Association (NACHA) and applicable state and federal laws. This authorization is for a single, non-recurring ACH debit only and does not permit recurring or future debits. If the debit is returned for insufficient or unavailable funds, I may be subject to applicable fees as permitted by law.

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Authorization & Consent
By signing below, I certify that I am an authorized signer on the bank account listed above and that the information provided is accurate.

THERE IS ABSOLUTELY NO EXTRA COST TO YOU!
Signature(Required)
Clear Signature

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 above, I certify that:

I am an authorized signer on the bank account listed above


THERE IS ABSOLUTELY NO EXTRA COST TO YOU!