E-Check Authorization

Authorize MedSafe to debit payments directly from your bank account using ACH. Safer than mailing a paper check. This is a free service.

Facility Name(Required)

Bank Routing Number (ABA)(Required)

Bank Name(Required)

Checking Account Number(Required)

Name on Account(Required)

This MUST be a business account. We are not authorized to process e-checks on personal accounts.

Account Address(Required)

Street Address City State ZIP Code

This is your mailing address that can be found on your check or bank statement.

Your Name(Required)

Must be someone who is authorized to make ACH payments from this bank account.

Email(Required)

Phone(Required)

Additional Comments?

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Today's Payment

If you are just authorizing E-check payments for future invoices, leave blank and check the box below.

Invoice Number

Account Number

Required to ensure proper assignment of authorization

To pay a specific invoice please enter the amount and invoice number.

To authorize e-check payment of all future invoices, check Save this Authorization.

Phone

This field is for validation purposes and should be left unchanged.

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