Nursing Home Direct Debit Authorization Form
Nursing Home Direct Debit Authorization Form
This Direct Debit Authorization Form is provided to facilitate the setup of automated payments for the services provided by [Your Company Name]. By completing and signing this form, you authorize [Your Company Name] to initiate recurring debits from your bank account for the specified services. Please ensure all information provided is accurate to prevent any processing delays.
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Personal Information |
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Patient Details |
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Name: |
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Date of Birth: |
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Address: |
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Phone Number: |
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Email Address: |
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Next of Kin / Legal Guardian Details |
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Name: |
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Relationship to Patient: |
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Address: |
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Phone Number: |
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Email Address: |
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Banking Information |
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Bank Name: |
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Account Holder Name: |
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Account Number: |
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Routing Number: |
Direct Debit Authorization:
I, [Patient's Name or Next of Kin / Legal Guardian's Name], hereby authorize [Your Company Name] to initiate debit entries to my/our [Bank Name] account indicated above at the depository financial institution named above, hereinafter called the "Bank", to debit the same to such account.
This authority is to remain in full force and effect until [Your Company Name] has received written notification from me/us of its termination in such time and in such manner as to afford [Your Company Name] and the Bank a reasonable opportunity to act on it.
Signature:
By signing below, I acknowledge that I have read and understood the terms of this authorization.
Patient's Signature:
Date:
Next of Kin / Legal Guardian's Signature (if applicable):
Date:
