CLEARING HOUSE APPLICATION FORM

PLEASE COMPLETE AND SUBMIT

CLEARING HOUSE APPLICATION FORM

We hereby wish to sign up with for your 'Clearing House Service'.

We require your full procedure to submit our 30 day+ accounts

Name
Title
Practice Name
Postal Address
Physical Address
E-mail:
Phone:
Fax:
Cell:
Contact Person

Debit Order Date

th Day of every Starting From

Debit Order Instruction

PAYMENT TYPE

Debit Order

Stop Order

Cheque

Debit Order Agreement with Exact Medical Solutions.

I/We hereby authorise , Exact Medical Solutions utilising the services of BDB Data Bureau to draw against my/our account an amount as determined in my/our Agreement with Exact Medical Solutions , on the th day of each and every month commencing on the until termination of the agreement by either party.

This authority may be cancelled by me/us by giving 30 (thirty) days notice in writing , sent by prepaid registered post , but I/we understand that I/we shall not be authorised to any refund of amounts which may have been withdrawn while this authority was in force if such amount were legally owing to Exact Medical Solutions. I /we agree to pay any Bank charges relating to this debit order instruction and understand that each withdrawal will reflected on my/our Bank statement and identified by code EMS. A cost of R 20.00 will be incurred on all rejected debit order payments.

Receipt of this instruction by Exact Medical Solutions will be regarded as receipt thereof by my/our Bank.

Details of my/our account are as follows :

Bank :

Branch:

Branch Code:

Account Nr:

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