AHCC Payment Form

AHCC PAYMENT AUTHORIZATION FORM      Use this form for New Enrollment or to change your Bank or Credit Card Provider Information:
If you are having the monthly payments deducted from your checking or savings account, please void a check for that account and attach to this form.



I authorize the financial institution named below to honor and pay the charges listed below at the frequency indicated. This authority is to remain in effect until revoked by me in writing and until you actually receive such notice. I agree that you shall be fully protected in honoring any such debit or credit charge. I understand that in order to cancel these automatic deductions, I must provide written notice to Apollo Health Care Cooperative no less than five (5) days before the next scheduled automatic deduction of charge.

Debit/Credit Card Number ______________________________________ Exp. Date_________
Name of the Account Holder ______________________________________________________
(Please print name as it appears on card)
Signature of Account Holder ________________________________ Date ________________
Print Name of Coop Member ________________________________________________
(If different from account holder)

Amount of Payment $____________ Monthly Billing Address Zip Code ________
Payment Start Date ___________ (For office use only)

OR Pay by:
I hereby authorize Apollo Health Care Cooperative, hereinafter called Company, to initiate debit entries and in the event of an erroneous debit entry, I authorize credit entries for adjustment to my account indicated below and the financial institution named below, hereinafter called Financial Institution, to credit and/or debit the same to such account. This authority is to remain in full force and effect until Company has received written notification from me of its termination in such time and in such manner as to afford Company and Financial Institution a reasonable opportunity to act on it.

Today’s Date  _______________
Financial Institution Name/Address  ___________________________________
Account Holder’s Name  ____________________________________________
Financial Institution Account # _______________________________________

Signature _________________________________ Amount of Payment $ ____________ Monthly
Name of Co-op Member ____________________________ (if different from account holder)

Check One:
I am not currently participating in the draft program:
____ADD – (Draft the account shown)

I am currently participating in the direct deposit program:
____CHANGE – (Change financial institution and/or bank account number)
____CANCEL – (Stop my participation in the program effective __________)
Select type of account: ____ Checking or ____ Savings Payment Start Date___________
*Apollo Health Care Cooperative will not be responsible for any charges from the bank if the account listed above

*** ATTACH YOUR VOIDED CHECK HERE *** Revision 2 /16/2011

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