Common use of Order Form Clause in Contracts

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 xxxx 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

Samples: Merchant Processing Agreement, Merchant Processing Agreement, Merchant Processing Agreement

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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 xxxx 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

Samples: Merchant Processing Agreement, Card Processing Agreement, Card Processing Agreement

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