DOCPAY Doctor Enrollment Agreement

(Print this document using your web browser "PRINT" button and fax the completed form to Complete Systems, Inc. at 254-772-4642 to enroll your practice with DOCPAY.)

Practice Name:___________________________________________________________________________

Practice Address: _______________________________________________________________________

                   ______________________________________________________________________

                   ______________________________________________________________________

Phone:________________________________________ Fax:______________________________________

Contact:_______________________________________Email:____________________________________

Bank Name: ______________________________________________________________________________

Name on Account: ________________________________________________________________________

Routing Number: _________________________________________________________________________

Account Number: _________________________________________________________________________


I, ______________________________________ authorize Complete Systems, Inc. (CSI) to print and deposit pre-authorized checks against my account for services rendered as follows:

What CSI will do: For each signed Patient Authorization form received from practice by CSI, CSI will establish a Pre-Authorized Checks Payment Plan and deliver to the above referenced address, multiple drafts for a specified amount each for the specified duration of the authorization. Doctor may at his own choosing charge patient as little or as much as he desires as a convenience fee. Regardless of the fee collected by doctor, CSI will draft the above referenced account $19.95 per DOCPAY Payment Plan established.

How you pay us: Each month, an invoice will be faxed or mailed listing the Payment Plans established in the prior month and the practice bank account will be drafted one week later for $19.95 times the number of plans established in the prior month.

Your responsibility: I also agree and understand that I am contracting with CSI solely for the printing and delivery of pre-authorized check drafts drawn on my patients' accounts. I understand that it is my responsibility to securely store the checks and deposit them according to the terms of my patients' authorization.

 

_______________________________________  ______________________
Authorized Signer for Referenced Account     Date



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Attach copy of $49.95 check from practice here
and fax this form to 254-772-4642


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