By signing this ACH Authorization Form (“ACH Form”), the undersigned (“Accountholder”) authorizes Nomi Health, Inc. (the “Company”) to credit or debit the account number listed above (the “Account”) as required or permitted in connection with the Accountholder’s relationship with the Company. In consideration of the provision of the Company services, Company shall deduct a 1% service fee from any payments made to Accountholder via this ACH Form. There is NO SERVICE FEE for ACH payments to Providers who are rendering Covered Services to a Member whose Plan Sponsor is a Nomi Health Network client. Accountholder also agrees to be bound by National Automated Clearing House Association rules (“NACHA”). These rules provide, among other things, that debits and credits are provisional until final settlement is made through a Federal Reserve Bank or payment is otherwise made as provided in Article 4A-403(a) of the Uniform Commercial Code.
In addition, Accountholder agrees Company may make adjustments to the Account whenever a correction or change is required. For example, if Company makes an error with respect to a debit or credit, you agree Company may correct such error immediately. The right to make such adjustments shall not be subject to any limitations or time constraints, except as required by law.The right to receive reimbursement for any ACH that is not authorized or is not consistent with this ACH Agreement. To obtain more information about your recourse rights, you can visit nacha.org. Accountholder agrees that Company may test the account by first crediting the Account in the amount not to exceed $1 and then debiting the same amount back. This will affirm the Account is set-up properly. Further, the above banking institution will be given notice by the Accountholder to REMOVE ANY DEBIT BLOCK OR DEBIT LIMIT for Company by providing a copy of this form to the financial institution listed above noting “Originating Company ID: 9671019212."
This ACH Form shall remain in effect unless and until Company has received written notification from Accountholder indicating that your authorization and this ACH Form have been terminated in such time and manner to allow Company to act. The undersigned represents and warrants that the person executing this ACH Form is an authorized Signatory on the Account referenced above and all information regarding the Account and Accountholder is true and correct.