ACH Payment Authorization Form

Holistic Practice Management

This secure form allows you to authorize automatic ACH payments for your Holistic Practice Management services. 
Your information is encrypted and stored securely in compliance with banking regulations. 
This is a one-time setup. Once completed, your monthly payments will be processed automatically.
We keep our costs low by reducing extra expenses, including credit card processing fees.
If you choose to use a credit card, we will add a 2% processing fee onto your monthly bill.

First Name

Last Name

Email *

Practice Name

Phone *

Associated with the Bank Account

By checking this box, I consent to receive non-marketing text messages from HPM about Billing. Reply STOP to opt out.

By checking this box, I consent to receive promotional messages including special offers, discounts, new product updates among others, from HPM at the phone number provided. Text STOP to opt out any time.

Address

Street Address

City

State

Country

Postal Code

Bank Routing Number (9 digits)

Bank Account Number

Confirm Bank Account Number

Account Type

ACH Payment Authorization Agreement

This authorization will remain in effect until I cancel it.
ACH transactions typically process within 2-3 business days
I will receive an invoice prior to each payment
I am responsible for ensuring sufficient funds are available in my account
Returned payments may be subject to a fee charged by my financial institution
HPM will maintain my banking information securely and use it solely for authorized payments.

Client Billing Signature *

Clear

I authorize Holistic Practice Management LLC to debit my account as described above. I have read and agree to the terms listed in the authorization agreement

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