New Client Enrollment Packet - Preferred Payment Plans

New Client Enrollment Packet Congratulations on taking the first step to increasing your Patients, Production and Profits! You will see just how easy it is with the right tools to automate your payments. To ensure compliance with all local, state and federal regulations, the following information about your organization is required. Thank you, The SterlingCare Team

Fax these documents to (888) 778-8604 or scan and email as an attachment to [email protected]. For your convenience, you can download and fill out these documents online at http://bit.ly/SCEnroll (PDF viewer required).

Questions? Call (800) 778-4640 to speak to a Business Specialist (M-F 8AM-5PM PST).

2865 East Coast Highway, Suite 320, Corona Del Mar, CA 92625 Phone: (800) 778-4640 Fax: (888) 778-8604 Email: [email protected] www.SterlingCarePlan.com

(800) 778-4640 • SterlingCarePlan.com

SterlingCare End-User License Agreement PLEASE READ THIS AGREEMENT CAREFULLY. THIS IS A BINDING AGREEMENT. BY USING THE CLIENT INITIATED PAYMENT PLAN, OR ANY PRODUCTS OR SERVICES PROVIDED IN CONNECTION WITH CLIENT INITIATED PAYMENT PLAN, YOU AGREE TO ABIDE BY THE TERMS OF THIS AGREEMENT, AS THEY MAY BE AMENDED BY STERLINGCARE, LLC FROM TIME TO TIME IN ITS SOLE DISCRETION. YOU AGREE THAT BY USING THE CLIENT INITIATED PAYMENT PLAN YOU REPRESENT THAT YOU ARE LEGALLY ABLE TO ENTER INTO THIS AGREEMENT. This End-User License Agreement (hereinafter “Agreement”) sets forth the terms and conditions under which Sterling Care, LLC (hereinafter “SterlingCare”) will license its software program, Client Initiated Payment Plan (hereinafter “the CIPP”) to Licensee. This Agreement is effective as of the date last executed, unless otherwise specified. 1.

Limited License

SterlingCare hereby grants Licensee a limited, non-transferable, non-exclusive license to access and use the CIPP; provided, however, that such license is subject to this Agreement and does not include: (a) any resale of the CIPP therein; (b) modifying or otherwise making any derivative uses of the CIPP, or any portion thereof, unless modification or derivative use is specifically provided for under separate terms; (c) use of any data mining, robots or similar data gathering or extraction methods; (d) downloading the CIPP, except as expressly permitted by SterlingCare; or (e) any use of the CIPP other than for its intended purpose. Any use of the CIPP other than as specifically authorized herein, without the prior written permission of SterlingCare, is strictly prohibited and will terminate the license granted herein. Such unauthorized use may also violate applicable laws including without limitation copyright and trademark laws, HIPAA statutes, and applicable communications regulations and statutes. Unless explicitly stated herein, nothing in this Agreement will be construed as conferring any license to intellectual property rights, whether by estoppel, implication or otherwise. This license is revocable at any time. 2.

Licensee’s Responsibilities

Licensee shall represent that it is a validly existing business entity, in good standing under the laws of the jurisdiction in which it operates, and has full power and authority to enter into this Agreement. Licensee further represents and warrants that the party executing this Agreement on behalf of Licensee is duly authorized to do so, and the execution, delivery and performance of this Agreement do not constitute a breach of the Licensee’s Articles of Incorporation, By-Laws, or other corporate governance, nor will the execution, delivery and performance of this Agreement constitute an event of default under any Agreement to which Licensee is now or may hereafter become a party. Licensee shall provide at its place of business the necessary equipment, personnel, materials, computer access and programming, reports, records, and cooperation necessary to perform the duties outlined in this Agreement. Licensee shall make appropriate its employees available for periodic in-service training by SterlingCare employees at mutually agreed upon times at Licensee’s place of business. Further, make appropriate employees accessible to SterlingCare by telephone during regular business hours to facilitate the successful performance of the duties of this Agreement. Licensee shall expend due and reasonable effort while conducting business with integrity in accordance with professional and ethical principles to facilitate the performance of the duties outlined in this Agreement. Licensee shall be responsible for all credit decisions including, but not limited to, whom to offer payment plans to; at what interest rate to offer payment plans at; the term of any payment plan arrangement; and the total amount of each payment plan. Licensee shall also retain responsibility for legal compliance with regards to Licensee’s business practices and those of Licensee’s employees, independent contractors, or consultants in accordance with any and all appropriate local, state, or federal jurisdictions. In order to access certain areas and features of the CIPP, Licensee shall register for an account. Licensee agrees to (a) provide accurate, truthful, current and complete information when creating an account; (b) maintain and promptly update your account information; (c) maintain the security of your account by not sharing your password with others and restricting access to your account and your computer; (d) promptly notify SterlingCare if you discover or otherwise suspect any security breaches related to the Site; and (e) take responsibility for all activities that occur under your account and accept all risks of unauthorized access.

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© 2014 SterlingCare®


Licensee agrees to use the following language in patient authorization form: “Patient/Sponsor authorizes SterlingCare, as agent of Provider, to debit funds from Patient/Sponsor’s Checking/Savings Account or Credit/Debit Card. This Automatic Payment Authorization is also applicable to any new Financial Institution information or Payment Information that may be provided by Patient/Sponsor. Patient/Sponsor agrees to provide new Financial Institution information in writing to the Provider’s Office at the address above at least 15 days prior to closing the Financial Institution account. Any changes in the terms in Payment Information must be approved by Provider and must be sent in writing to the Provider’s Office at least 15 days before the change can take effect. Patient/Sponsor may cancel this Automatic Payment Authorization by providing written notice to the Provider’s Office five (5) or more business days prior to the payment due date. There is a $25 charge for all returned items due to insufficient funds. In the event of insufficient funds when payment is due from Primary Payment Method, Patient/Sponsor authorizes SterlingCare to charge the Secondary Payment Method for amounts up to and including the unpaid balance. Upon default of the above payment schedule due to insufficient funds, withdrawal of this Automatic Payment Authorization, nonpayment, or bankruptcy, the entire unpaid balance including unpaid interest may, at the option of Provider, be declared immediately due and owing. In the event of default, Patient/Sponsor agrees to pay reasonable costs of collection and/or attorney’s fees as permitted by California law. Neither Provider nor SterlingCare is liable for any damages resulting from the transfer of funds unless due to fraud or willful misconduct. Patient/Sponsor understands that he/she has the duty to review all monthly statement from the Financial Institution reflecting funds transferred per this Automatic Payment Authorization and inform Provider of any errors in such statement within 30 days of receipt.” 3. Payment Terms Use of CIPP requires Licensee to pay a onetime enrollment fee (“Enrollment Fee”) in order to access all parts of the CIPP. Enrollment fees are non-refundable. Enrollment Fee is subject to change at any time by SterlingCare. Enrollment Fee (one time):

$99.00

Use of the CIPP requires Licensee to pay a payment plan set-up fee for each CIPP created (“Set-Up Fee”). Each Set-Up Fee is non-refundable. Set-Up Fee is subject to change at any time by SterlingCare. Once the CIPP has been set up, Licensee is required to pay a fee for any requests for changes to the CIPP that require the change to be made by SterlingCare personal such as, but not limited to, payment account changes, balance adjustments and cancelations (“Change Fee”). Each Change Fee is non-refundable. Change Fee is subject to change at any time by SterlingCare. Set-Up Fee (for each CIPP): $25.00 Change Fee (for each CIPP): $5.00 per change request Licensee is responsible for fees related to or charged by bank and credit card companies used in the CIPP (“Processing Fees”). Although SterlingCare will use reasonable efforts to establish relationships with its various processing providers to minimize Processing Fees, Licensees understands Processing Fees often vary and frequently change and Licensee remains responsible for the Processing Fee. Use of the CIPP requires Licensee to pay Sterling Care a service fee (“Service Fee”) on the sum total collected each month from the Licensee’s patient on behalf of the Licensee (“Net Collected Funds”) at the following rates: $1 to $25,000 in Net Collected Funds: $25,001 to $50,000 in Net Collected Funds: 1.45% Above $50,000 in Net Collected Funds: 4.

1.95% 0.95%

Privacy Policy

SterlingCare is committed to respecting the privacy rights of the Licensee and its patients in regards to the use of CIPP. If applicable, SterlingCare will comply with the Health Insurance Portability and Accountability Act (HIPAA) and protect any individually-identifiable patient data (“Protected Health Information”) as a result of the relationship between SterlingCare and the Licensee. SterlingCare will: (a) not use or further disclose Protected Health Information except as permitted or required by law; (b) use appropriate safeguards and comply, where applicable, with the security rule under 45 CFR, parts 160 and 164 subpart C with respect to electronic Protected Health Information, to prevent use or disclosure of Licensee’s Protected Health Information; (c) report to Licensee within fifteen (15) days of becoming aware of any security incidents, use or disclosure Protected Health Information; (d) ensure that SterlingCare’s subcontractors that create, receive, maintain or transmit Protected Health Information on behalf of SterlingCare, agree in writing to the same restrictions and conditions that apply to

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SterlingCare; and (e) make Protected Health Information that SterlingCare stores or maintains for Licensee available to enable Licensee to meet its obligation in accordance with the applicable laws. SterlingCare may use or disclose Licensee’s Protected Health Information for the management and administration of SterlingCare’s company, to carry out SterlingCare’s own legal responsibilities or if SterlingCare obtains reasonable assurance from the recipient of the Protected Health Information (1) that it will be held in confidentiality and used or further disclosed only as required by law for the purposes for which it was disclosed to the recipient and (2) that the recipient will notify SterlingCare of any instances of which the recipient is aware in which the confidentiality of the information is breached. 5.

Intellectual Property Rights and Infringement

Unless otherwise indicated, SterlingCare, the CIPP and all content and other materials related to SterlingCare and the CIPP, including, without limitation, the SterlingCare logo, and all designs, text, graphics, pictures, information, data, software, sound files, other files and the selection and arrangement thereof are the proprietary property of SterlingCare or its licensors or users and are protected by U.S. and international trademark and copyright laws. Licensee may not copy, imitate or use, in whole or in part, proprietary property of SterlingCare without the prior written permission of SterlingCare or the applicable trademark holder. Licensee may not use any metatags or any other “hidden text” utilizing “SterlingCare” or any other name, trademark or product or service name of SterlingCare without our prior written permission. In addition, the look and feel of the CIPP, including all page headers, custom graphics, button icons and scripts, is the service mark, trademark and/or trade dress of SterlingCare and may not be copied, imitated or used, in whole or in part, without our prior written permission. All other trademarks, registered trademarks, product names and SterlingCare names or logos mentioned in the CIPP are the property of their respective owners. 6. Term and Termination The initial term of this Agreement is one (1) years, beginning on the Effective Date, and will automatically renew for successive one (1) year periods, unless terminated by either part as set forth below. Either party may, at is option, terminate this Agreement immediately upon written notice, if the other party breaches or is in default of its obligations as set forth in this Agreement; provided, however, the party in default will have thirty (30) days to cure such default following written notice of default from other party. Either party may, at its option, terminate this Agreement without cause upon ninety (90) day written notice to the other party. 7.

Indemnity

Subject to the terms of this Agreement, Licensee will defend SterlingCare, its affiliates, and its and their respective officers, directors, employees and agents (each a “SterlingCare Indemnitee”) from any claims, demands, actions, suits, prosecutions and other proceedings brought by or on behalf of a third party (each a “Claim”), and will indemnify and hold the SterlingCare Indemnitees harmless from all damages, liabilities, losses, fines, penalties, judgments, awards, settlements, costs and expenses (including reasonable attorneys’ fees and costs, consequential damages or any exemplary or punitive damages, unless any of the foregoing are awarded to the third party or included in an assessment or penalty by a governmental authority, which award, assessment or penalty is the subject of indemnification under this Agreement) (collectively, “Losses”) incurred by any of them due to, a Claim that arises from or is related to any actual or alleged: (a) breach by Licensee of this Agreement; (b) failure by Licensee to comply with any representation and/or warranty contained in this Agreement; (c) Licensee’s failure to comply with applicable law; (d) negligence or intentional misconduct by Licensee or its employees; (e) claim or action that is based on false or allegedly false or misleading statements or representations related to use of the CIPP or otherwise made by Licensee; and/or (f) claim or action that is based on collection practices used by Licensee related to the use of CIPP. Notwithstanding the foregoing, Licensee will have no obligations under this Section to the extent any Losses arise or result from any Claim for which SterlingCare is required to indemnify Licensee under this Section, or the gross negligence or intentional misconduct of SterlingCare or its employees. Subject to the terms of this Agreement, SterlingCare will defend Licensee and its officers, directors, employees and agents (each an “Licensee Indemnitee”) from, and will indemnify and hold the Licensee Indemnitees harmless from all Losses incurred by any of them due to a Claim that arises from or is related to any actual or alleged gross negligence or intentional misconduct by SterlingCare or its employees. Notwithstanding the foregoing, SterlingCare will have no obligations under this Section to the extent any Losses arise or result from any Claim for which

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Licensee is required to indemnify SterlingCare under this Section, or the gross negligence or intentional misconduct of Licensee or its employees. Each party will promptly notify the other party of any notice of the commencement or filing of any Claim for which the other party is entitled to indemnification under this Agreement and the indemnified party will provide reasonable assistance, at the indemnifying party’s request and sole expense, needed in the defense or settlement of any Claim. The indemnifying party will have sole control of the defense and settlement of any Claim; however, no compromise or settlement may be committed to without the indemnified party’s prior written consent unless: (a) it includes a full discharge and release of liability for the indemnified party, (b) it has no effect on any rights or obligations of the indemnified party, or on any Claims that may be made by or against the indemnified party, and (c) there is no injunctive or other equitable relief entered against the indemnified party. The indemnified party also may elect to participate in the defense of any Claim at its own expense with counsel of its choice. 8.

Disclaimer

EXCEPT AS EXPRESSLY PROVIDED TO THE CONTRARY IN A WRITING BY STERLINGCARE, THE CIPP CONTAINED THEREIN ARE PROVIDED ON AN “AS IS” BASIS WITHOUT WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED. STERLINGCARE DISCLAIMS ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, INCLUDING, WITHOUT LIMITATION, IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE AND NON-INFRINGEMENT AS TO THE CIPPAND THE SERVICES, INCLUDING THE INFORMATION, AND CONTENT CONTAINED THEREIN. STERLINGCARE DOES NOT REPRESENT OR WARRANT THAT THE CIPP ARE ACCURATE, COMPLETE, RELIABLE, CURRENT OR ERROR-FREE. WHILE STERLINGCARE ATTEMPTS TO MAKE YOUR ACCESS AND USE OF THE CIPP SAFE, STERLINGCARE CANNOT AND DOES NOT REPRESENT OR WARRANT THAT THE CIPP OR ITS SERVER(S) ARE FREE OF VIRUSES OR OTHER HARMFUL COMPONENTS; THEREFORE, YOU SHOULD USE INDUSTRY-RECOGNIZED SOFTWARE TO DETECT AND DISINFECT VIRUSES. 9.

Limitation of Liability

IN NO EVENT WILL STERLINGCARE, ITS MEMBERS, DIRECTORS, OFFICERS, EMPLOYEES OR AGENTS BE LIABLE FOR ANY DIRECT, SPECIAL, INDIRECT OR CONSEQUENTIAL DAMAGES, OR ANY OTHER DAMAGES OF ANY KIND, INCLUDING BUT NOT LIMITED TO LOSS OF USE, LOSS OF PROFITS OR LOSS OF DATA, WHETHER IN AN ACTION IN CONTRACT, TORT (INCLUDING, BUT NOT LIMITED TO, NEGLIGENCE) OR OTHERWISE, ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE USE OF OR INABILITY TO USE THE CIPP, INCLUDING, WITHOUT LIMITATION, ANY DAMAGES CAUSED BY OR RESULTING FROM RELIANCE BY YOU ON ANY INFORMATION OBTAINED FROM STERLINGCARE, OR THAT RESULT FROM MISTAKES, OMISSIONS, INTERRUPTIONS, DELETION OF FILES, ERRORS, DEFECTS, VIRUSES, DELAYS IN OPERATION OR TRANSMISSION OR ANY FAILURE OF PERFORMANCE, WHETHER OR NOT RESULTING FROM ACTS OF GOD, COMMUNICATIONS FAILURE, THEFT, DESTRUCTION OR UNAUTHORIZED ACCESS TO STERLINGCARE’S RECORDS, PROGRAMS OR SERVICES. IN NO EVENT WILL THE AGGREGATE LIABILITY OF STERLINGCARE, WHETHER IN CONTRACT, WARRANTY, TORT (INCLUDING NEGLIGENCE, WHETHER ACTIVE, PASSIVE OR IMPUTED), PRODUCT LIABILITY, STRICT LIABILITY OR OTHER THEORY, ARISING OUT OF OR RELATING TO THE USE OF OR INABILITY TO USE THE CIPP OR TO THESE TERMS OF USE EXCEED ANY COMPENSATION YOU PAY, IF ANY, TO STERLINGCARE FOR ACCESS TO OR USE OF THE SITE. 10.

Jurisdiction and Waiver of Jury Trial

By entering into this Agreement, Licensee and SterlingCare agree that the exclusive jurisdiction for the institution and maintenance of any action for judicial relief shall be in either the State Courts sitting in Orange County, California or the United States District Court for the Central District of California (Southern Division). Licensee hereby waives any claim that such court does not have personal jurisdiction over it or for inconvenient forum. STERLINGCARE AND LICENSEE ACKNOWLEDGE THAT THE RIGHT TO TRIAL BY JURY IS A CONSTITUTIONAL RIGHT, BUT ONE THAT MAY BE WAIVED. AFTER CONSULTING (OR HAVING HAD THE OPPORTUNITY TO CONSULT) WITH COUNSEL OF THEIR CHOICE, KNOWINGLY AND VOLUNTARILY, AND FOR THEIR MUTUAL BENEFIT, STERLINGCARE AND LICENSEE WAIVE ANY RIGHT TO TRIAL BY JURY IN THE EVENT OF LITIGATION REGARDING THE PERFORMANCE OR ENFORCEMENT OF, OR IN ANY WAY RELATED TO THIS AGREEMENT. 11.

California Use Only

The CIPP is controlled and operated by SterlingCare from its offices in the State of California. SterlingCare makes no representation that any of the materials or the services to which you have been given access are available or appropriate for

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use in other locations. Your use of or access to the CIPP should not be construed as SterlingCare’s purposefully availing itself of the benefits or privilege of doing business in any state or jurisdiction other than California. 12.

Severability and Waiver

If, for whatever reason, a court of competent jurisdiction finds any term or condition in this Agreement to be unenforceable, all other terms and conditions will remain unaffected and in full force and effect. No waiver of any breach of any provision of this Agreement will constitute a waiver of any prior, concurrent, or subsequent breach of the same or any other provisions hereof, and no waiver will be effective unless made in writing and signed by an authorized representative of the waiving party. 13.

Modifications

SterlingCare may, in its sole discretion and without prior notice, (a) revise this Agreement; (b) modify the CIPP, or any features or portions thereof; and (c) discontinue the CIPP, or any features or portions thereof, at any time. SterlingCare will post any revision to this Agreement to the SterlingCare’s website www.sterlingcareplan.com, and the revision will be effective immediately on such posting. You agree to review this Agreement and other online policies posted on SterlingCare’s website periodically and to be aware of any revisions. You agree that, by continuing to use or access the CIPP following notice of any revision, you will abide by any such revision. 14.

Notices

All notices or demands hereunder shall be in writing and shall be deemed delivered if personally delivered or sent by registered mail, postage prepaid as follows: SterlingCare, LLC 2865 East Pacific Coast Highway, Suite 320 Corona Del Mar, CA 92625 Phone: 800-778-4640 Fax: 888-778-8604

___________________________________________ (Licensee Name)

___________________________________________ (Licensee Street Address)

_____________________, _________ ___________ (City)

(State)

(Zip)

_____________________ _____________________ (Licensee Phone)

(Licensee Fax)

[SIGNATURE PAGE TO FOLLOW]

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BY USING THE CIPP, YOU ACKNOWLEDGE THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO BE BOUND BY THE TERMS OF THIS AGREEMENT. Executed this _________ day of _________________, _________ at Orange County, California

SterlingCare, LLC Client

Authorized Signature


Name

Name

Title

Title

15. Email Address Please provide an email address and contact name you wish to use as you primary login to the client portal. Your credentials will be sent to this email address to gain access to the SterlingCare secured portal.

Email Address

Primary Contact Name

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W-9

Form (Rev. December 2011) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Print or type See Specific Instructions on page 2.

Name (as shown on your income tax return) Business name/disregarded entity name, if different from above

Check appropriate box for federal tax classification: Individual/sole proprietor

C Corporation

S Corporation

Partnership

Trust/estate Exempt payee

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶ Other (see instructions) ▶ Address (number, street, and apt. or suite no.)

Requester’s name and address (optional)

City, state, and ZIP code List account number(s) here (optional)

Part I

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Social security number

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Employer identification number

Part II

–

–

–

Certification

Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4.

Sign Here

Signature of U.S. person ▶

Date ▶

General Instructions Section references are to the Internal Revenue Code unless otherwise noted.

Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of effectively connected income.

Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income.

Cat. No. 10231X

Form W-9 (Rev. 12-2011)


Payment Authorization Form 1. Authorization Agreement I, ____________________, of _________________________ authorize SterlingCare LLC (SterlingCare®) to charge my Bank Account or Credit Card immediately for the amount of $99.00 as a one-time Enrollment Fee for SterlingCare®’s services. 2. Account Information (choose one option below) a. Charge to Bank Account

☐ Checking

☐ Savings

Name of Financial Institution

Routing Number

Account Number

Name on Account

b. Charge to Credit Card

Name on Card

☐ Visa . i n ☐ MasterCard ☐ Discover ☐ American Express

Card Number

Expiration Date

3. Signature


Date

Created: 3/25/2014



Direct Deposit Agreement Form (OPTIONAL*) 1. Authorization Agreement I, ____________________, of _________________________ authorize SterlingCare LLC (SterlingCare®) to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to my (our) account(s) indicated below and to other accounts I (we) identify in the future (the “Account”). This authorizes the financial institution holding the Account to post all such entries. I agree that the ACH transactions authorized herein shall comply with all applicable U.S. Law. Further, I agree not to hold SterlingCare® responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing or withdrawing funds to my account. This agreement will remain in effect until SterlingCare® receives a written notice of cancellation from me or my financial institution, or until I submit a new Direct Deposit Agreement Form to SterlingCare® and SterlingCare® has a reasonable opportunity to act on it. 2. Account Information

☐ Checking

☐ Savings

Name of Financial Institution

Routing Number

Account Number

Name on Account

3. Signature


Date

Please attach a voided check or deposit slip. *If you chose not to enroll in Direct Deposit, SterlingCare will disburse your funds by check mailed via USPS on a weekly basis and email you a Weekly Statement and notice of deposit.

Created: 3/25/2014
