Inovalon/Ability Connectivity Solution Fee
TO ACCEPT THE PAYMENT PLAN
1) Mark the box before type of account to indicate whether your payment will be deducted from your checking or savings account.
2) Fill in your name AND financial institution information.
3) Attach a voided check for verification of all financial institution information. If you are unable to attach the voided check, please fill in your account number and routing number.
NOTE: Be sure to sign the form!
I authorize Prime Clinical Systems to initiate electronic debit entries to my:
___ checking account (or) ___ savings account for payment.
PLEASE DEDUCT: $55.00 MONTHLY(up to 10,000 transactions annually, overages(.10 cent per transaction) do not apply to this fee and will be billed separately)
I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
This authority will remain in effect until I have cancelled it in writing.
Date__________________________________________________________
FINANCIAL INSTITUTION NAME (PLEASE PRINT) _______________________________________________________
ACCOUNT NUMBER AT FINANCIAL INSTITUTION ______________________________________________________
FINANCIAL INSTITUTION ROUTING NUMBER _________________________________________________________
FINANCIAL INSTITUTION CITY AND STATE ____________________________________________________________
____________________________________________ ____________________________
SIGNATURE DATE CLIENT ID
**YOU MAY FAX THIS FORM TO, ARMINEH ALBARIAN, OFFICE ADMINISTRATOR – 626-449-0164**
*Ability Connectivity Solution Monthly Fee, $55.00 and must be paid via Prime Clinic Systems ACH account*