I authorize Orthodontic Associates to complete the Financial Payment Information in accordance to our signed contract on file.

I also authorize regularly scheduled charges to my checking/savings account or credit card. You will be charged each billing period for the total amount due for that period and the charge will appear on your bank or credit card statement. I agree that no prior notification will be provided and the transaction will be made according to my financial contract with Orthodontic Associates.

I understand that this authorization will remain in effect until I cancel it in writing, or balance is paid in full, and I agree to notify Orthodontic Associates in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH transaction being rejected for Non-Sufficient Funds (NSF) I understand that Orthodontic Associates may at its discretion attempt to process the charge again within 30days,and agree to an additional $25 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment.

I certify that I am an authorized user of this credit card/bank account and will not dispute the scheduled transactions with my bank or Credit Card Company: provided the transactions correspond to the terms indicated on this authorization form.