Request To Close RPA

Request To Close Reversal Prepayment Account

Use this form to close your Reversal Prepayment Account
By submitting this release you are authorizing closure of your Reversal Prepayment Account with A Personal Choice.

To close your Reversal Prepayment Account you must submit this form.

You will be notified when your request has been completed.
Reversal Prepayment Account Closure
When closing your account you will be refunded your money less a $500 Reversal Prepayment Account administration fee.
Acknowledgement of Reversal Prepayment Account Closure
Enter your name as it appears on your records at our facility.*

First NameLast Name
Enter your date of birth:*

MonthDayYear
Date
I understand there is a $500 Reversal Prepayment Account administration fee for account closures and this fee is not refundable.*

I understand
I understand any amount in my Reversal Prepayment Account in excess of $500 will be refunded by check within fifteen (15) business days.*

I understand
What address would you like us to mail your refund to?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the reason for closing your Reversal Prepayment Account?*
Do you have any comments for our staff?
Please upload an image of the front of your photo ID (ie driver's license).*

Cancelof
Best phone number: Our office will call you to verbally confirm your request to close your Reversal Prepayment Account. What is the best phone number to call and verify your request to close your RPA?*
Please enter a valid phone number.
If our staff is unable to reach you at the number above to confirm your request to close your Reversal Prepayment Account we will consider this signed, electronic request an official cancellation of your prepayment account.
Best email address: What is the best email address for you?*

Confirmation Emailexample@example.com
By submitting this form you are officially closing your Reversal Prepayment Account on the date this form is electroncially submitted to our office.
Patient signature*

Clear
Date*

MonthDayYear
Date
Staff Documentation of RPA Closure
I called the number above to verbally confirm RPA closure.*

I spoke directly with patientI was unable to reach patient
Patient verbally confirmed their name and date of birth.*

Patient verbally confirmed their name and date of birth.
Patient verbally confirmed they uploaded photo ID. Name and date of birth on ID match patient name and date of birth*

Patient verbally confirmed they upload photo ID and name and date of birth on photo ID.
Patient is aware of the $500 RPA administration fee that is not refundable.*

Patient verbally confirmed they understood
Patient desires to*

Close reversal prepayment accountContinue with reversal prepayment account
Confirmed accuracy of address to mail refund check*

Address confirmed
Staff comments:
Staff member's name*

First NameLast Name
Staff signature*

Clear
Date of staff documentation of cancellation*

MonthDayYear
Date
1. Save this form in the patient's electronic financial folder.

2. Archive this form in JotForms.
Should be Empty:

Request To Close Reversal Prepayment Account

Reversal Prepayment Account Closure

Acknowledgement of Reversal Prepayment Account Closure

Staff Documentation of RPA Closure