Order Form. Merchants accepting Preauthorized Health Care Transactions must have the Cardholder complete an order form containing the following: a. a request for the services to be charged to the Cardholder’s account; b. assignment of insurance benefits to you; c. authorization for you to charge the Cardholder’s account for only that portion of the bill subsequent to your receipt of any applicable insurance payment; d. duration of time, not to exceed 1 year, for which permission is granted; and e. if the Preauthorized Health Care Transaction is renewed, the Cardholder must provide an updated order form.
Appears in 6 contracts
Sources: Card Processing Agreement, Card Processing Agreement, Merchant Processing Agreement
Order Form. Merchants accepting Preauthorized Health Care Transactions must have the Cardholder complete an order form containing the following:
a. a request for the services to be charged to the Cardholder’s account;
b. assignment of insurance benefits to you;
c. authorization for you to charge the Cardholder’s account for only that portion of the bill ▇▇▇▇ subsequent to your receipt of any applicable insurance payment;
d. duration of time, not to exceed 1 year, for which permission is granted; and
e. if the Preauthorized Health Care Transaction is renewed, the Cardholder must provide an updated order form.
Appears in 3 contracts
Sources: Merchant Processing Agreement, Merchant Processing Agreement, Merchant Processing Agreement