Make a Secure Online Payment

As the account holder (or authorized user) attached to this payment, I permit Elevate Care LLC to debit the amount above on today's date (or next business day) as an electronic funds transfer via ACH or credit/debit card. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF), I understand that Elevate Care LLC may at its discretion attempt to process the charge again, and agree to an additional $25 charge or amount allowable by law for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.