SAMPLE
Dr. Michael Turner, DDS
Dear Patient,
We are happy to introduce a new Automated Payment Plan. This program will save us time and money by reducing our payment processing costs. It will also free our staff so they can concentrate on patient care & other important operating aspects of my practice.
It will also also provide a savings to you. You will no longer need to write out the check, find an envelope and address it, stamp it, and make sure it is in the mail on time. It will all be done for you.
We do this through the use of a bank draft which is drawn on your designated account on the same day each month. This paper draft is just like a check, and will be returned to you with your monthly statement.
All we need is the following authorization form to be filled out and mailed to our office. Please call if you have any questions.
Thank you,
Dr. Michael Turner
Bank Draft Authorization
Your Name (as shown on your account)______________________________________________
Bank Name___________________________Checking Account #_________________________
I authorize bank drafts on the above account in the amount of $_______________ per month until a total of
$_______________has been drafted from my account. This draft in to begin on _____________________and on the same day of the month each month thereafter.Signature ______________________________________Date_________________________________
(Attach a voided check from the authorized account)