Business Associate Agreement - TriZetto Provider Solutions LLC - EMS Billing Services

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AUTOMATIC PAYMENT AUTHORIZATION E TriZetto Provider Solutions, LLC ("TriZetto") offers a free automated payment service ("Automatic Payment") through an automated clearinghouse ("ACH"). With Automatic Payment, Client's monthly invoices will be paid from Client's bank account. Client will continue to receive invoices but instead of writing a check, Automatic Payment deducts the invoiced amount from Client's bank account in order to pay the TriZetto invoiced amount. Client's bank statement will reflect these payments as separate transactions, so Client will have a payment record. There are no late fees or lost checks and Client's payments are made precisely on an agreed upon date. To activate Automatic Payment, complete the information below. For assistance with Automatic Payment, please call 800-969- 3666 and ask for Sales. is hereby authorized by Client to charge the following bank account and remit payments fname of financial institution) V monthly for Client's invoices to TriZetto Provider Solutions, LLC. - ACH account as follows: ❑ Monthly (payment to be taken out the 20th of each month) AND / OR ❑ One-time transaction for payment of Initial Set-up Fee as set forth on the Purchase Order upon receipt by TriZetto. Bank Account Owner Bank Account Number ABA/Routing Number CREDIT CARD • . I TriZetto accepts MasterCard, Visa, and American Express cards for payment of the Initial Setup Fee listed on the Purchase Order. To charge Client's credit card for the Initial Setup Fee, TriZetto requires the information below. TriZetto will charge Client's credit card within seven business days of TriZetto's receipt of this Authorization. _.� ................ Client Name: South Bend Fire Department Site No.: Name on Email: Credit Card: Telephone Fax: ............................................. Billing Address Ci Stat�Zi Visa / Exp. Date: CVV#/CVC#:(3 digits on back) _MasterCard #: AmericanE.._x p_ Date. _____------...._......_.- .....m......................... CID#:(4 digits on front) Express#: )................................ .............................. ... By signing below, I authorize TriZetto Provider Solutions to charge the credit card listed above for the Initial Setup Fee as set forth on the Purchase Order. To witness its understanding, the Client has caused its duly authorized representative to sign this Authorization form on its behalf. The individual signing below on behalf of Client personally represents that, to the best of his or her knowledge, he or she has been duly authorized to sign this Authorization form on the Client's behalf. Signature: Scan, fax, or mail this signed Authorization form to: SALES REP: Angie Rinderer Name: �- Attention TPS Sales 66 Title: , TriZetto Provider Solutions, LLC Fax: 314-802-682 3300 Rider Trail South Fax: 314-802-6822 Date: Earth City, MO 63045 form reviewd A �fC i'f.Al„ Y 4 bifeu�ewmeN�! II