Scribd
Upload
694 views1 page

Refund Form South African Bank Account New

This document is a patient refund banking details form for a South African citizen to provide bank account information to receive potential refunds from Drs du Buisson, Kramer, Swart, Bouwer Inc. It requests the patient's account or invoice number, electronic fund transfer details including account holder, bank name, branch name and code, account number and ID number. It includes a declaration waiving claims against the doctors if the information is incorrect and they pay the refund into the wrong account.

Uploaded by

Mark Pather
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
694 views1 page

Refund Form South African Bank Account New

This document is a patient refund banking details form for a South African citizen to provide bank account information to receive potential refunds from Drs du Buisson, Kramer, Swart, Bouwer Inc. It requests the patient's account or invoice number, electronic fund transfer details including account holder, bank name, branch name and code, account number and ID number. It includes a declaration waiving claims against the doctors if the information is incorrect and they pay the refund into the wrong account.

Uploaded by

Mark Pather
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

PATIENT REFUND BANKING DETAILS INFORMATION FORM: SA CITIZEN / BANK

Dear Sir / Madam,

Account/Invoice Number :

Kindly supply Drs du Buisson, Kramer, Swart, Bouwer Inc with your bank account details, or the bank account
details of the person you have nominated to receive your potential refund, in order for us to facilitate the process
going forward:

Please note: Proof of payment must accompany this form

Electronic Fund Transfer

Account Holder :

Bank Name :

Branch Name :

Branch Code :

Account Number:

I.D Number :

Declaration

I, , I.D number hereby


confirm that the information provided above is correct and that any refund due to me may be processed as per
above instructions.

I waive any claims against Drs du Buisson, Kramer, Swart, Bouwer Inc should the information supplied above be
incorrect and Drs du Buisson, Kramer, Swart, Bouwer Inc paid the potential refund into an incorrect bank
account. I understand that if I have nominated a third party to receive the potential refund on my behalf that
Drs du Buisson, Kramer, Swart, Bouwer Inc has no liability should I not be able to obtain payment from such
third party.

Name and Surname of authorized Signature

person supplying details

Date Contact Number

PLEASE EMAIL THIS COMPLETED AND SIGNED FORM TO: [email protected]

You might also like