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Primary Contact Name (First and Last):

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(First and Last)

Primary Contact Title:

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NPI (10 digits):

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Agency Name:

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Primary Contact Phone:

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Ext:

Fax Number:

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Contact Email:

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Patient Sample Start Year:

Patient Sample Start Month:

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Software Company:

Data Collection Mode:

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REMINDER
Phone and mixed-mode will be conducted in English and Spanish.

REMINDER
Mixed-mode will be conducted in English and Spanish.

REMINDER
Mail mode will be conducted in English and Spanish.

How did you hear about us:

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Billing Information

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Payment Method:

Check

Credit Card Information

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Expiration Date (MM):

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Expiration Date (YY):

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I authorize Fields Research to make recurring charges to my Credit/Debit card listed above, and if necessary, to initiate adjustments for any transactions credited or debited in error. This authority will remain in effect until Fields Research has received written notification from me to cancel it. The notice must be received by Fields Research within seven days before the recurring charge date to cancel the next payment. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company, provided the transactions correspond to the terms indicated in this authorization form.

e-Check Information

Bank Name:

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9-digit Routing Number:

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Account Number:

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Agreement: ACH Authorization for CCD Transactions

This Agreement governs ACH transactions initiated by Fields Research to credit or charge the Company indicated above. Both parties agree to be bound by NACHA Operating Rules as they pertain to all ACH transactions initiated by Fields Research that credit or debit the Company bank account listed above, and acknowledge that the origination of ACH transactions to the listed account must comply with provisions of U.S. law.

This Agreement provides authorization for individual or recurring CCD (Cash Concentration and Disbursement) transactions to be initiated by Fields Research. This Agreement will remain in effect until Company listed above cancels it in writing. Both parties agree that this Agreement in conjunction with any of the designated methods constitutes authorization to debit Company’s business bank account, and Company agrees not to dispute any debits with its bank provided the transaction(s) correspond to the terms indicated in this Agreement.

I certify that I am an authorized representative of the Company indicated above and that I have the authority to enter into this Agreement on the Company’s behalf. Company understands that this authorization will remain in effect until it is canceled in writing, and agrees to notify Fields Research in writing at least 15 days in advance of any changes in its account information or termination of this authorization. Company understands that because these are electronic transactions, these funds may be withdrawn from its account as soon as the date an individual transaction is authorized, and that it will have limited time to report and dispute errors. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) Company understand that Fields Research may at its discretion attempt to process the charge again within 30 days, and agrees to an additional $30 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. Company has certified that the above business bank account is enabled for ACH transactions, and agrees to reimburse for all penalties and fees incurred as a result of Company’s bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions. Company acknowledges that the origination of ACH transactions to its account must comply with the provisions of U.S. law.

Agreement

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If you have any questions please contact the Fields Research CG-CAHPS Team at (513) 821-6266