Payment Authorization — Award HomeCare

Billing Contact

First name

Last name

Email (invoices sent here)

Phone

Billing address

City

State

ZIP

Client name (if different from billing contact) Relationship to client

Payment Method

e-Check / ACHPreferred — no processing fee Credit CardAccepted — 3% processing fee applies

🔒 Secure payment details

Your card or bank details will be collected here through our secure, PCI-compliant payment processor. No card or account number is stored by this form. (Processor integration pending — for now, Award HomeCare will collect payment details securely by phone at 732-994-0309.)

Recurring Billing Authorization

By signing below, I authorize Award HomeCare, Inc. to automatically charge the payment method I provide for services rendered, on the following terms:

A two-week deposit is due at the start of care, applied toward the final bill and refundable per the Service Agreement.
Award HomeCare invoices and charges my payment method on file every other Monday after services are rendered.
Invoices are emailed to the billing contact above; I am responsible for reviewing them (including spam/junk folders).
Credit card payments incur a 3% processing fee; e-Check / ACH has no fee.
If a payment fails, Award HomeCare will contact me for an alternate method; unpaid balances may incur late fees within legal limits.
This authorization remains in effect until I cancel it in writing, and does not relieve me of responsibility for services already rendered.
Rates may change per the Service Agreement (including the 5% annual increase on January 1).

I understand a two-week deposit is due at the start of care. I authorize Award HomeCare to charge my payment method on file on the recurring biweekly basis described above.

↑ Scroll to the bottom of the authorization to enable the checkbox.

Signature

Cardholder / account holder — type full name

Date

Typing your name constitutes a legally binding electronic signature authorizing recurring payment.