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.
When closing your account you will be refunded your money less a $500 Reversal Prepayment Account administration fee.
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.
By submitting this form you are officially closing your Reversal Prepayment Account on the date this form is electroncially submitted to our office.
1. Save this form in the patient's electronic financial folder.
2. Archive this form in JotForms.