Direct Debit - Patient Billing

TEST MODE — this form is connected to DocuSign’s demo environment. Signatures made here are for testing only and are not legally binding.

patientbilling

Direct Debit Instruction

Setting up or changing the account you pay Patient Billing from? Complete the pages below, then sign your new Direct Debit Instruction electronically — it replaces your existing instruction and is stored securely in DocuSign.

1Your Details
2Direct Debit
3Review & Sign

Direct Debit form patientbilling

Your Details

So we can match this instruction to your account.

First name * Surname * Professional Number * GMC, HCPC or other professional body number — so we can match your account Email address * Your signing request is linked to this address Telephone Optional — in case we need to confirm anything

Direct Debit form patientbilling

Instruction to your bank or building society to pay by Direct Debit

🔒 Your bank details are used only to prepare the Direct Debit Instruction you are about to sign in DocuSign. They are not stored on this website.

Is this instruction for: * Credits Debits Both Credits — payments made to you · Debits — payments collected from you · Both

Name(s) of account holder(s) * Branch sort code * Bank/building society account number * Bank/building society name * To: The Manager

Bank address *

Postcode *

Your payments are protected by the Direct Debit Guarantee. Banks and building societies may not accept Direct Debit Instructions for some types of account.

Direct Debit form patientbilling

Review & Sign

I confirm I am the account holder, that no other signature is required to authorise Direct Debits on this account, and I authorise Patient Billing Limited to prepare my Direct Debit Instruction for electronic signature. *

Direct Debit Instruction

Your Details

Instruction to your bank or building society to pay by Direct Debit

Review & Sign

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