ACH Bank Payments – Advocate Insurance Billing

ACH Recurring Payment Authorization Form

Your Name*
Owner or authorized agent/representative of the clinic.
First Last
What email address do you want invoices to go to?*
Phone*
Account Type*
- Business Checking
- Business Savings
- Personal Checking
- Personal Savings
Bank Name*
Routing Number*
Please enter the entire number, even if it starts with zero(s). Routing numbers are always 9 digits!
Account Number*
Please enter the entire number, even if it starts with zero(s).
Legal Clinic Name*
Clinic Address*
Street Address Address Line 2 City State ZIP Code
Start Date*
MM slash DD slash YYYY
Authorization*
Starting on the date I have chosen above, I authorize Kings Royal Services LLC (DBA Advocate Insurance Billing) to electronically debit my bank account on or after the 10th of every month for the amount due as detailed in the invoice sent to me or my staff.

This payment authorization is to remain in full force and effect until I notify Kings Royal Services LLC of its cancellation by sending written notice in such time and in such manner to allow both Kings Royal Services LLC and the receiving financial institution a reasonable opportunity to act on it.

In case of an ACH transaction being rejected for Non Sufficient Funds (NSF) I understand that Kings Royal Services LLC may at its discretion attempt to process the charge again within 30 days, 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 agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.
- Yes
- No