Ally Client Payment Agreement – Page 1

Client Payment Agreement

This Client Payment Agreement (the “Agreement”) entered into on the date first written below, is by and between the undersigned recipient (as defined below), an individual residing at the address listed below (together with recipient’s Authorized Representative, if any), herein referred to as the “Client”, and Ally Home Care, LLC (“Ally”), a Pennsylvania limited liability company (collectively, the “Parties” and each a “Party”). Accordingly, the Parties agree as follows:

1. Payments to Ally by you:

As consideration for the services provided by Ally hereunder, you agree to pay Ally a fee equal to three percent (3.00%) for Bank Charge (ACH), or five percent (5.00%) for credit card (Visa, MasterCard, Discover) or six point five percent (6.50%) for American Express, or Client initiated payment methods, of the total amounts owed to: (a) your care provider/caregiver(s) for the care they provided to you, including all expenses incurred; and (b) the fees owed to your referral agency as a result of your receipt of such care (collectively, the “Ally Fee”). After you have executed this agreement and returned a signed copy to Ally, Ally will begin receiving Electronic visit data from your caregiver(s) and will charge or debit your account each week as provided herein. The amount charged to your credit card, debited to your bank account, or deducted for your Ally balance in the event of a client initiated payment structure, each week will equal the sum of: (i) the amount owed to your caregiver(s) for the care they provided to you; (ii) the corresponding amount payable to your Referral agency; and (iii) the corresponding Ally Fee. You acknowledge and agree that all such fees, charges, and costs are subject to change and that the Ally Fee may be adjusted from time to time by Ally in writing. You also agree to promptly provide Ally with written notice of any changes to the credit card and bank account information you provide to Ally and acknowledge that any delay in payment to Ally may result in a delay of payment to your caregiver(s). You agree that you are solely responsible for any issues that may arise because of delay of payment to your caregiver(s).

2. Payment Methods: Ally accepts payment via bank charge (ACH), VISA, MasterCard, American Express or Discover for any Client balances. Client’s preferred payment method (the “Payment Method”) and contact information must be provided by Client in Exhibit A of this Agreement. Client agrees to maintain at all times valid Payment Method(s) on file with Ally capable of satisfying any accrued Total Billings. Client agrees to promptly provide Ally with written notice of any changes to Client’s Payment Method and/or update payment method on file directly in the software system. Client acknowledges that failing to pay for services for any reason will interrupt caregiver payments and services and is liable for total billings.

3. Payment Authorization: Client authorizes Ally to automatically charge Client’s Payment Method for the accrued balance of Total Billings each Billing Cycle, all in accordance with the terms and conditions set forth herein. Client further understands that the names “Ally Senior Care Pmt” or “Ally Caregiver Payments” may appear on their credit card or bank statement with respect to these charges. Client will be charged $25.00 for any invalid chargeback made to an Ally charge to the client payment method on file.

4. Payment Responsibility: Client is responsible for payment of any accrued Client balance each Billing Cycle. Any outstanding Client portion of Total Billings not paid within thirty (30) calendar days of the applicable Billing Cycle will accrue simple interest at a rate of one and one-half percent (1.5%) per month on the unpaid portion. Client agrees that Client is liable for all amounts due to caregivers, Client’s referral agency and Ally for services provided. In the event Client is unable or unwilling to fully satisfy any financial obligation under this Agreement, the entire amount owed will be deemed an obligation of his or her guarantor, if applicable, and/or any estate applicable to Client. Notwithstanding anything contained herein, Ally may refer collection of any amounts due hereunder to any collection agency and/or attorney, and Client will be liable for the payment of any and all costs and expenses, including reasonable attorney’s fees, associated with any such collection effort.

5. Billing Information: Client acknowledges that Ally conducts its billing processes based on information provided to it by client’s caregiver in the form of an electronic visit record. Client is responsible for confirming and verifying visit information prior to Ally charging account on file. Ally is not responsible for verifying the accuracy of the information provided to it, and will not be responsible for errors that result from Ally’s reliance on such information.

6. Effect of Non-Payment: Client understands and acknowledges that non-payment of any Client balance for any reason may interrupt caregiver Services and that Client is responsible for any issues or liabilities that arise from not satisfying caregiver payments. Client further acknowledges that if Client’s Payment Method shall become invalid at any time due to insufficient funds, closed account or any other reason, that Ally will discontinue Ally services until a valid Payment Method is supplied. Ally will additionally notify Client’s caregivers and referral agency if Client Payment Method becomes inactive or invalid for any reason.

7. Term; Termination: The term of this Agreement will begin on the date first executed below and will continue until it is terminated by either Party as provided herein. This Agreement may be terminated at any time by either Party upon prior written notice. Upon termination of this Agreement, a final reconciliation of Client’s account will occur, and Client will promptly pay any outstanding amounts due at that time, regardless of the reason for termination. Termination of the Agreement will not relieve Client of the obligation to pay for services rendered prior to the date of termination.

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Ally Home Care Agreement – Page 1

8. Notices: Any notice required hereunder may be given by FedEx, United Parcel Service or other similar express service that maintains tracking and delivery records, or via First Class U.S. Mail postage prepaid to either Party at their respective addresses set forth herein or to such other address as either Party may specify to the other in writing.

9. Electronic Visit Verification: Client agrees that their caregivers must use the Ally electronic visit verification system for logging care activity. Client agrees that electronic visit verification validates care and all care invoices will be delivered electronically.

10. Miscellaneous: This Agreement (including Exhibit A hereto, which is hereby incorporated into and made a part of this

Agreement): (a) contains the entire understanding of the Parties with respect to the subject matter covered herein and supersedes any prior agreements with respect to such subject matter, whether oral or written; (b) may only be amended by a written instrument signed by both Parties; (c) shall be governed by the laws of the Commonwealth of Pennsylvania, without regard to applicable conflicts of law provisions; (d) may be executed in one or more counterparts; (e) may not be assigned by Client; and (f) shall be binding upon the Parties’ successors in interest, permitted assigns, legal representatives, heirs, and beneficiaries. If any part of this Agreement is held void or unenforceable, it shall not affect the validity of the balance of the Agreement. The failure of any Party to insist upon strict performance of any provision herein shall not be construed as a waiver. Any waiver by either Party of any breach of any term or condition hereof shall be effective only if in writing and such writing shall not be deemed to be a waiver of any other breach, term or condition of this Agreement.

IN WITNESS HEREOF, intending to be legally bound, the Parties hereto have caused this Agreement to be duly executed as of the date first written. By signing below I agree to be responsible as a surety to pay for any and all charges or fees for Caregiver Services provided to Client and corresponding referral agency and Ally fees.

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Ally Payment Authorization Form – Page 2

CLIENT

Signed:

Print Name:

Date:

CLIENT’S POWER OF ATTORNEY, AUTHORIZED REPRESENTATIVE, OR FINANCIALLY RESPONSIBLE PARTY

Signed:

Print Name:

Date:

Ally Home Care, LLC

Signature of Ally Home Care, LLC

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Ally Payment Authorization Form – Page 4

Signature:

Date: / /

BACKUP PAYMENT METHOD (optional)
If paying by bank charge (ACH):
Check One:	Checking		Savings
Name on Account:		Payment Frequency: Weekly
Financial Institution:		Payment Start Date: / /
City:	State:	Zip:
Routing/ABA #:	Account #:
I hereby authorize Ally Home Care (Ally) to debit entries, and if necessary credit entries to correct erroneous debits from the account at the Financial Institution named above. If a debit is scheduled to take place on a non-banking date, the transaction will take place on the next banking day. I (we) acknowledge the origination of ACH transactions to our account must comply with the provisions of U.S. law. This authority is to remain in full force and effect until Ally has received written notification from me of termination in such time and manner as to afford Ally and Financial Institution a reasonable opportunity to act on it. Debit amount to be provided via invoice prior to ACH debit.
Signature:			Date: / /

** Please attach a voided check to set up bank transfer (ACH) payments **

If paying by Credit or Debit Card:
Check One:	Visa	MasterCard		Discover	AmEx
Cardholder’s Name:				Payment Frequency: Weekly
Billing Address:				Payment Start Date: / /
Billing Email (required):				Billing Phone: () –
Card Number:		Exp. Date: /	CVV:
City:	State:	Zip:
I hereby authorize Ally Home Care (Ally) to charge the credit card listed above for the payment of all services and fees. This credit card will be kept on file and will remain in effect until further notice from client. If you should need to notify us of your intent to cancel and/or revoke this authorization you must contact us 30 days prior to the questioned debit being initiated.
Signature:					Date: / /

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Ally Payment Authorization Form

Exhibit A: Payment Authorization Form

Client Information:
First:	Last:
Address:
City:	State:	Zip:
Home Phone:	Mobile Phone:
Email (Required):	SSN:

PRIMARY PAYMENT METHOD
If paying by bank charge (ACH):
Check One:	Checking		Savings
Name on Account:		Payment Frequency: Weekly
Financial Institution:		Payment Start Date: / /
City:	State:	Zip:
Routing/ABA #:	Account #:
I hereby authorize Ally Home Care (Ally) to debit entries, and if necessary, credit entries to correct erroneous debits from the account at the Financial Institution named above. If a debit is scheduled to take place on a non-banking date, the transaction will take place on the next banking day. I (we) acknowledge the origination of ACH transactions to our account must comply with the provisions of U.S. law. This authority is to remain in full force and effect until Ally has received written notification from me of termination in such time and manner as to afford Ally and Financial Institution a reasonable opportunity to act on it. Debit amount to be provided via invoice prior to ACH debit.
Signature:			Date: / /

** Please attach a voided check to set up bank transfer (ACH) payments **

If paying by Credit or Debit Card:
Check One:	Visa	MasterCard		Discover	AmEx
Cardholder’s Name:				Payment Frequency: Weekly
Billing Address:				Payment Start Date: / /
Billing Email (required):				Billing Phone: () –
Card Number:		Exp. Date: /	CVV:
City:	State:	Zip:
I hereby authorize Ally Home Care (Ally) to charge the credit card listed above for the payment of all services and fees. This credit card will be kept on file and will remain in effect until further notice from client. If you should need to notify us of your intent to cancel and/or revoke this authorization you must contact us 30 days prior to the questioned debit being initiated.

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Send to BONJOUR

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