Options Counseling and Family Services

Amount (USD $)

Billing Information

Telephone:

Email:

Additional Information

*Client Account # from statement: *Client Date of Birth: *Client Name:

ACH Bank Payment Agreement

You authorize Options Counseling and Family Services to debit this bank account for all amounts authorized by you in accordance with your agreement(s) with Options Counseling and Family Services for goods or services.

This agreement applies only to the method of payment between you and Options Counseling and Family Services and this agreement and any termination of this agreement does not have any effect whatsoever with respect to any contract for goods or services between you and Options Counseling and Family Services. You may terminate this agreement at any time by contacting Options Counseling and Family Services at billing@options.org.

All debits to your account will be administered by our payment services provider, Helcim USA

Merchant Policy

Administrative Office
541-687-6983
541-762-1571 Fax
3500 Chad Drive, Suite 350
Eugene, OR 97408
Options Records Requests
541-320-9009 Fax