HealthSource ACH AutoPay Enrollment

ACH AutoPay Enrollment

P: 410-653-1113 F: 410-415-7004 www.HealthSourceDistributors.com

Already a HealthSource customer? Use this form to have your invoices paid automatically from your bank account.

Applicant Information

Applicant Name *Applicant Email Address *

A copy of this form will be emailed to the applicant email address when you submit.

Pharmacy Information

Name of Pharmacy *Pharmacy's Accounting Contact Name *Pharmacy Phone Number *Billing Email Address *DEA Number (if you have one)HealthSource Account Number (if you know it)

Below please enter your address as it appears on your State BOP license.

Pharmacy Address *City *State *Zip Code *

Payment Information

Name of Financial Institution *Name on the Bank Account *Financial Institution Address *City *State *Zip Code *

Type of Account *

Checking Savings

Depositor Account Number *Nine Digit Routing Number *

Billing Dates: Semi Monthly Payment
All invoices from the 1st to the 15th of the month will be withdrawn on the 30th of the same month (or the last business day proceeding the 30th). All invoices from the 16th to the end of the Month will be withdrawn on the 15th of the following month (or the last business day proceeding the 15th).

Authorization & Signature

The undersigned agrees that the following terms and conditions are applicable to all purchases made by Applicant and shall constitute a contract between the Applicant and HealthSource Distributors, LLC. This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment-related information processed through the Vendor Express Program. Recipients of these payments should bring this information to the attention of their financial institution when presenting this form for completion.

Privacy Act Statement: The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System.

I agree to sign this application electronically. I understand my signature below has the same effect as a handwritten signature, and that I can ask for a paper copy at any time. *

Signature *

Sign with your mouse or finger.

By clicking Sign and Submit you are signing this enrollment electronically.