TERMS AND CONDITIONS FOR ONE-TIME CHARGE OR DEBIT
I hereby authorize the named medical provider to initiate a charge or debit entry on my credit card, debit card or checking account (as applicable) in an amount equal to the amount I entered on the payment entry screen. This authorization will remain in full force and effect until the transaction has been processed and the funds have been transferred to and received by the named medical provider.
TERMS AND CONDITIONS FOR RECURRING CHARGES OR DEBITS
I hereby authorize the named medical provider to initiate a charge or debit entry on my credit card, debit card or checking account (as applicable) for the total amount identified in the agreed upon payment plan has been paid in full. This authorization will remain in full force and effect until the date upon which the balance has been paid in full or until such time as I terminate this authorization in writing by providing the above named provider with a written notice, at least 72 hours prior to my next scheduled payment, of the termination of this authorization signed by me. I agree to maintain an available balance sufficient to pay all authorized payments, and agree that the named medical provider is not liable for any overdraft or insufficient balance situation or charge (including, but not limited to, finance charges, late fees or similar charges) caused by my failure to maintain a balance sufficient to pay all payments issued through this payment plan. I further agree that the named medical provider may charge a reasonable service fee for any charge or debit transactions that result in a returned debit entry, including, but not limited to, returns resulting from insufficient available balance in my account, closure of my account or incorrect account or routing information provided by me. Said fee shall not exceed ten dollars ($10.00). I agree to promptly notify the named medical provider in writing of any changes to the financial institution account information and hereby grant authority for the named medical provider to charge or debit such changed account. I agree that the named medical provider will not be responsible for any expense that I may incur from exceeding my credit limit or overdraft of my account as a result of a charge or debit made pursuant to this payment plan.
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Refunds are processed immediately and will be applied back to your credit card according to your credit card issuer.