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. *

I agree to the terms and conditions: X
Physician
Bank Account *
Business Name on the Check *
Exactly as it appears on the check.
Full Name on the Check *

Prefix First Name Middle Name Last Name Suffix
Murlidhar A. Amin, MD, PA

2300 HWY 365, Ste. 150

Nederland, Texas 77627
Date / Time *

Month Day Year Hour Minutes AM/PM Option
Name
Signature *

Clear
Bio Scans Reimbursed

Please check each scan once you have received reimbursement from the insurance provider.
Jan 2019 AMIN Paid Claims
Feb 2019 AMIN Paid Claims
March 2019 Paid Claims
April 2019 Paid Claims
May 2019 Amin Paid Claims
June 2019 Amin Paid Claims
July 2019 Amin Paid Claims
August 2019 Amin Paid Claims
September 2019 Amin Paid Claims
October 2019 AminPaid Claims
Nov 2019 Amin Paid Claims
Dec 2019 Amin Paid Claims
Jan 2020 Amin Paid Claims
Feb 2020 Amin Paid Claims
March 2020 Paid Claims
April 2020 Paid Claims
May 2020 Paid Claims
ITHRIVE Health LLC.

Screenings@ITHRIVEhealth.com

888.982.8539
Should be Empty:

Payment Authorization