AutoPay Enrollment "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged. Good News! We are now pleased to offer enrollment into Recurring Quarterly Autopayment. Please elect one of the following payment options below:* ACH Direct Debit from your Checking or Savings Account Credit Card Payment **Please note: A 3% convenience fee will be added to your invoice when paying via credit cardPharmacy Name*DEA #*Email Address* Phone Number*ACH Direct DebitI authorize GeriMed LTC Network Inc.* I authorize GeriMed LTC Network Inc., hereinafter called COMPANY, to initiate debit entries to my account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY. Also, if necessary, initiate adjustments for any transactions debited in error. Depository Bank Name*Bank Address* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Account Type* Checking Savings Bank Routing Number (ABA #)*Bank Account Number* This authorization will 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 DEPOSITORY a reasonable opportunity to act on it. Please attach a copy of a VOIDED check for the account listed above*Max. file size: 50 MB. Credit Card PaymentI give permission to GeriMed* I give permission to GeriMed LTC Network Inc. to charge my card for the following purchases. My card details will be stored in my profile and will only be used for Membership Fees. Amount Authorized*Total To Be ChargedIncludes 3% convenience feeCard Type* MasterCard Discover VISA AMEX Other Cardholder (Name on card)*Card Number*Valid CVV*Expiration Date*ZIP Code*Date* MM slash DD slash YYYY Customer Name*Customer Signature*
