ACH Payment Form

Patient Name*
Physician*
Invoice #
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
ACH
Account Number Account Type Routing Number Account Holder Name
Payment Amount*
Comments
Client authorizes a one time and/or regularly scheduled charges to Client’s banking or credit account in the amount entered above. Client understands that ACH debits are electronic transactions, and these funds may be withdrawn from Clients’ account upon submission. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) Client understands that Total Access Medical may at its discretion attempt to process the charge again within 48-hours. Client acknowledges that the origination of ACH transactions to Clients’ account must comply with the provisions of U.S. law.
Your security is important to us. Payments processed through this portal are encrypted and transmitted via a secure socket layer to a PCI-compliant payment processor. This technology which ensures that your information is being handled in accordance with industry-recognized standards.