CARD AUTHORIZATION ON FILE AGREEMENT

(Telehealth or Brick-and-Mortar)

Date: {{current_date}}

Member Information

• **MEMBER NAME:** {{patient_input}}
• **DOB:** {{patient_input}}

Insurance Options

If you choose not to use your insurance for any future services, such as continuing lab work and medications, you must inform us.

OPTION 1: ☐ I choose to use my insurance for future services, such as continuing lab work and medications. In the event that insurance does not cover these services, I agree to pay out of pocket for the difference.

OPTION 2: ☐ I choose not to use my insurance for future services such as continuing lab work and medications.

INITIALS: {{patient_input}}

Required Primary Payment Card for Membership Fees

Account Number: {{patient_input}}

Card Issuer (Visa, Mastercard, etc.): {{patient_input}}

Card Type:

• Credit Card
• Debit Card
• HSA
• FSA

Expiration Date: {{patient_input}}

CVV Code: {{patient_input}}

Billing Address & ZIP Code: {{patient_input}}

Secondary Payment Card for Membership Fees

Account Number: {{patient_input}}

Card Issuer (Visa, Mastercard, etc.): {{patient_input}}

Card Type:

• Credit Card
• Debit Card
• HSA
• FSA

Expiration Date: {{patient_input}}

CVV Code: {{patient_input}}

Billing Address & ZIP Code: {{patient_input}}

ACH Information

Account Holder Name: {{patient_first_name}} {{patient_last_name}} {{patient_input}}

Bank Routing Number: {{patient_input}}

Bank Account Number: {{patient_input}}

Account to Charge for Prescriptions & Lab Testing (Select One):

• Primary Card
• Secondary Card
• ACH

Acknowledgment and Agreement

I acknowledge I have received a list of pre-negotiated pricing for various prescriptions, supplements and labs. I understand that these prices are subject to change over time. I further understand I will be responsible for these costs, or the balance of what insurance may not cover (the lesser of the two). I have been informed that New Vitalis LLC is affiliated with BSM Holdings, LLC and that I have the right to choose my pharmacy.

I hereby authorize this Merchant (ennu, Concordia Practice Management, LLC, BSM Holdings, LLC, Body Shapes Medical Management, LLC and/or its assigns and third-party vendors, including New Vitalis Pharmacy), to keep my account information on file for payment and to initiate debit or charge entries on this account as amounts are owed for the Member Account listed above. I acknowledge that the transactions to my account must comply with U.S. law. I understand that a charge may be made to my credit card account periodically to pay for amounts owed, and this charge may come from the Merchant or any elected third-party health care provider. If my credit card information listed above changes for any reason, I will notify the Merchant immediately. This authorization shall remain in effect until the Merchant has received notice from me of its termination. In the event of a declined charge, my account may be charged a $25.00 service fee for each occurrence.

Initials: {{patient_input}}

Signature

Cardholder Signature: {{patient_input}} Date: {{patient_input}}

BSMM Card Authorization Agreement 2025.04.16

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Card Authorization on File Agreement

Unique Document ID: e3614b78bcc7e0c6ce32b6da1457702afb422c47

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Party ID: 912778d3-c6da-470f-8c3c-b93a78d14947

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Party ID: 9b317c7c-cb4c-47e2-b751-d35f95204d2d

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Party ID: 53ef3992-70b1-4f77-87d7-c48bb41977d1

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Party ID: 11dd3bef-afec-4606-b3c4-4f5bcddac8b2

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Timestamp	Audit
2026-03-03 09:12:15 UTC	Document Card Authorization on File Agreement Uploaded by EnnuLife - docs-admin-ennulife@ennulife.com IP: 0.0.0.0

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