Paid Claims- DR. Amin

Payment Authorization
I authorize Ithrive Health & Wellness, LLC and or Gregory Rainbolt to initiate either an electronic debit or to create and process a demand draft against my bank account for each Bio Scan checked below. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.
Physician
Bank Account
Business Name on the Check
Exactly as it appears on the check.
Full Name on the Check

PrefixFirst NameMiddle NameLast NameSuffix
Murlidhar A. Amin, MD, PA

2300 HWY 365, Ste. 150

Nederland, Texas 77627
Date / Time

MonthDayYearHourMinutesAM/PM Option
Name
Signature
Bio Scans Reimbursed

Please check each scan once you have received reimbursement from the insurance provider.
Aug 2022 Amin Paid Claims
Sept 2022 Amin Paid Claims
Oct 2022 Amin Paid Claims
Nov 2022 Amin Paid Claims
Dec 2022 Amin Paid Claims
Jan 2023 Amin Paid Claims
Feb 2023 Amin Paid Claims
ITHRIVE Health LLC.

Screenings@ITHRIVEhealth.com

888.982.8539
Should be Empty:

Payment Authorization