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The form instructs the signer to confirm the correct ACH bank routing number and account number with their financial institution, list all associated NPIs, and provide financial institution information, routing number, and account number. It requires attachments including a voided check or bank letter (if applicable) and a completed Form W-9 (Rev. March 2024), plus signature, date, and contact details for processing.",{"@graph":63,"@context":123},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/ach-authorization-form/288382/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/ach-authorization-form/288382.png","ImageObject",442,249,{"name":88,"@type":89},"Ethan Miller","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115,119],{"name":106,"@type":107,"acceptedAnswer":108},"What information is required to process the ACH authorization?","Question",{"text":109,"@type":110},"The form requires the company/provider name, tax ID, complete financial institution details, the ACH routing number and account number, and all NPIs associated with the listed company and tax ID.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the authorization work for credits and potential debits?",{"text":114,"@type":110},"It authorizes Leon Health, Inc. to initiate ACH credit entries and, if necessary, debit entries and adjustments for any credit entries made in error.",{"name":116,"@type":107,"acceptedAnswer":117},"What documents must be attached before submission?",{"text":118,"@type":110},"Attach a voided check or a letter from your bank (if the ACH routing number differs) and a completed Form W-9 (Rev. March 2024).",{"name":120,"@type":107,"acceptedAnswer":121},"When does the authorization remain effective, and how can it be cancelled?",{"text":122,"@type":110},"The authority remains in effect until cancelled in writing by the signer, and ACH/Wire originations must comply with the provisions of U.S. law.","https://schema.org",{"og:url":78,"og:type":125,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":127,"canonical":78},"index,follow",{"doc_id":129,"site_id":56},288382,1789633426,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":88,"user_avatar":134,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":130,"read_time":4},687207017582,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","All information is required before processing  \nPlease contact your Financial Institution to confirm the appropriate ACH bank routing number and correct bank account number. These numbers may differ from your checking account number and wire routing number.  \nCompany/Provider Name:   Federal Tax ID Number:   \nAddress:    \nNPI:   ;   ;   ;   ;   ;    \nPlease list ALL of your NPI’s associated with the above Company Name/TAX ID and this banking information.  \nI hereby authorize Leon Health, Inc. , to initiate credit and, if necessary, debit entries and adjustments for any credit entries in error to my: (select one) □ Checking Account or □ Savings Account indicated below, at the depository Financial Institution named below, and to credit or debit the same from such account. I acknowledge that the authority will remain in effect until I have cancelled it in writing and that the origination of ACH/Wire transactions to my account must comply with the [provisions of U.S. law](provisions of U.S. law).  \n(Name of Financial Institution)  \n(Address of Financial Institution-City, State & Zip Code)  \n(ACH Routing Number) (Account Number)  \n(Please attach a voided check or letter from your bank (if the ACH routing number is different) AND a completed  \nForm W-9 (Rev. March 2024)  \nThis authorization is to remain in full force and effect until Leon Health, Inc. has received written notification from me of its termination in such time, and in such manner as to afford Leon Health, Inc. and Financial Institution a reasonable opportunity to act on it.  \nAuthorized by:  Phone Number:   \nPrint Name and Title  \nEmail Address:   \nSignature:  Date:   \nNOTE: If all information on the enrollment form is not provided or is provided incorrectly, there maybe a delay in processing.  \nPlease send the completed form with the required attachments to:  \n[cash_management@leonmedicalcenters.com](cash_management@leonmedicalcenters.com)  \nInternal use only: Provider ID:   \nW9 received:   \nVerified by:   Date:   Voided check or Bank letter received:   \nACH effective date:    \nVerified with:","cbCaifvYUnbh1dvj","https://ap.wps.com/l/cbCaifvYUnbh1dvj","pdf",280064,"English","# Required information\n## Financial institution and account details\n## NPI listing and authorization terms\n# Required attachments and submission\n## Void check or bank letter and Form W-9\n## Email submission and internal verification fields","[{\"question\":\"What information is required to process the ACH authorization?\",\"answer\":\"The form requires the company/provider name, tax ID, complete financial institution details, the ACH routing number and account number, and all NPIs associated with the listed company and tax ID.\"},{\"question\":\"How does the authorization work for credits and potential debits?\",\"answer\":\"It authorizes Leon Health, Inc. to initiate ACH credit entries and, if necessary, debit entries and adjustments for any credit entries made in error.\"},{\"question\":\"What documents must be attached before submission?\",\"answer\":\"Attach a voided check or a letter from your bank (if the ACH routing number differs) and a completed Form W-9 (Rev. March 2024).\"},{\"question\":\"When does the authorization remain effective, and how can it be cancelled?\",\"answer\":\"The authority remains in effect until cancelled in writing by the signer, and ACH/Wire originations must comply with the provisions of U.S. law.\"}]","ACH authorization form | PDF"]