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.

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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.

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