EFT Authorization Agreement (CMS 588)

EFT Authorization Agreement Date: 1 November 2024 Patient Name: Sarah Johnson Date of Birth: 15/03/1985 Address: 123 Elm Street, Anytown, AB1 2CD Phone Number: 07700 900123 Email Address: sarah.johnson@example.com I, Sarah Johnson, hereby authorise [Your Practice Name] to initiate electronic debit entries (EFT) to my financial institution account as specified below, for payment of services rendered. This authorisation is for recurring payments for physiotherapy sessions and related charges. Bank Name: Barclays Bank Account Holder Name: Sarah Johnson Account Number: 12345678 Sort Code: 20-30-40 This authorisation will remain in effect until revoked by me in writing. I understand that I must provide [Your Practice Name] with a minimum of 30 days written notice to revoke this authorisation. I also understand that I am responsible for ensuring sufficient funds are available in my account to cover authorised debits. Authorised Signature: Sarah Johnson Printed Name: Sarah Johnson Practice Name: Optimal Health Physiotherapy Clinic Practice Representative: David Miller Date: 1 November 2024 This agreement was explained to the patient, and they confirmed understanding and agreement to the terms.