Fill - Free fillable Optum Pay Fee Cancellation Form (Microsoft) PDF form

Optum Pay Fee Cancellation Form

Please use this form to cancel your premium-level access to the Optum Pay™ portal. This form will not cancel your

ACH payments and it will also not cancel your TIN enrollment. You can also complete the cancellation process

online by visiting the Solutions tab. Upon completion, you acknowledge that all users associated with the below TIN

will have limited features/functions, including:

• Access to 13 months of claim payment data

• No search capabilities

• No access to the data bundle

• No access to workflow management tool

Questions? Please call us at 1-877-620-6194 if you have any questions while completing this form.

*All fields marked with an asterisk (*) are required.

1 Health care organization information — required

Organization name*: TIN*:

Address*:

Administrator name*:

Administrator email*:

Administrator phone number*:

Cancel effective date: Immediately*: ___________ Future effective date*: __________ (next billing cycle)

2 Reason for cancellation of Optum Pay full functionality

Please let us know why you would like to cancel your Optum Pay full-service activation so we can better serve you in the future (check all

that apply):

I don’t use the portal as often as I thought I would

I receive my data from a clearinghouse

I don’t need the search tools

I don’t need historical claim data

The service is too costly for my practice

Other: ________________________________________________________________

3 Administrator authorization

The cancellation process may take up to seven days to process. If you would like to reinstate the full functionality of Optum Pay, please visit

optum.com/optumpay.



Signature of administrator on file*

Date*

Printed name of administrator on file*

Where to return your form?

By email: optumpay_cancel@optum.com

click to sign

signature

click to edit

4/2021

Optum Pay™ Enrollment Agreement Terms and Conditions

In addition to the agreements, conditions, covenants, certifications, documents, disclosures and notices you received and

consented to in the Optum Pay Enrollment Agreement (“Enrollment Agreement”), and the Optum Financial, Inc., Internet

Website Terms of Use (“Website Terms”), the following terms and conditions, as amended from time to time, shall

supplement the Enrollment Agreement and Website Terms and shall collectively apply to and govern all use of Optum

Financial,

Inc.’s Optum Pay solution, and the use of any product or service provided in connection therewith (collectively the

“Optum Pay

Services”).

Please note that these terms and conditions require the use of arbitration to resolve

disputes, rather than courts or jury trials, and limit the remedies available in the event of a dispute.

In these

terms and conditions, the words “you” and “your” means the organization, entity or entities, and individuals identified

on the

Enrollment Agreement

you submitted to us or that you subsequently identify as a

primary or other user and

the words “we,” “our,” “us” refers to Optum Financial, Inc., its affiliates, designees and other

service providers

(collectively, “Optum”). Your enrollment, registration, use or allowance of another person to use the Optum Financial, Inc.,

Internet Website or Optum Pay Services signifies your acceptance and consent to be legally bound by the Enrollment

Agreement, the Website Terms, the terms and conditions of this document and any applicable agreement, condition,

covenant, certification, document, disclosure and notice referenced herein or related thereto (collectively “Agreement”).

1. Subscriptions. You can acquire Optum Pay Services for free (a “Free Subscription”) or for a charge. If your organization has

elected to receive ACH payments from Payers (defined below), you may purchase access to certain payment features or

services on a subscription basis (“Paid Subscription”). The Free Subscription and Paid Subscription will be collectively referred

to herein as a “Subscription”. Upon election by you of a Paid Subscription such Paid Subscription shall remain in effect unless

cancelled by you. To cancel a Paid Subscription: (i) log in to the Optum Pay Website using your username and password; and

(ii) follow the instructions provided to cancel or modify your enrollment. Any changes in your enrollment in an Optum

Pay payment services plan may take up to seven (7) business days to process and you will be responsible for any

charges to your Account(s) (defined below) until such changes are in effect as determined by Optum. For each Paid

Subscription, you authorize us to charge the account(s) listed on your Enrollment Agreement, or any other account otherwise

provided to Optum for payment of the Paid Subscription, (the “Account” or “Accounts”), at a time and for the amounts

described in the Paid Subscription. ACH charges to your Accounts will use Optum Pay as the ACH Company Name and

1243848776 as the ACH Company ID. If you have enrolled in a Paid Subscription and an ACH debit block filter has been

placed on your Accounts, you will need to grant us authorization to originate charges by adding the ACH Company Name

“Optum Pay” and the ACH Company ID “1243848776” to the ACH debit block white list maintained by each financial

institution holding your Accounts. If we cannot charge your Account(s) for any reason (such as a debit block or insufficient

funds), and you have not cancelled the Paid Subscription, you remain responsible for any uncollected amounts, including any

applicable debit block or insufficient funds fees, and we will attempt to charge your Account(s) again. Optum reserves the

right to make other payment methods available to you and to discontinue or limit the use of a payment method at any time

and without notification. Use of another payment method, excluding ACH payments described in this section, may be subject

to additional terms and conditions. Prices for Paid Subscriptions are assessed on a monthly basis and may change at any time.

If required, we will notify you if the price of a Paid Subscription increases or if we seek your consent to continue. We reserve

the right to cancel your Paid Subscription if we are unable to successfully charge your Account(s). You may be provided with a

free trial of a Paid Subscription prior to charging your Account(s). If you decide to unsubscribe from a Paid Subscription before

we start charging your Account(s), you must cancel the Paid Subscription before the free trial ends. Charges for Paid

Subscriptions do not include any taxes or duties including but not limited to Federal, State, Municipal excise, sales, use and

any other similar taxes, duties and charges of any kind imposed by any governmental authority on any amounts payable by

you. Any taxes or duties that are due and owing hereunder shall be paid by you. Optum may revise its charges or any invoice

to include any and all taxes or duties that may become due hereunder and Optum may invoice you for said additional tax

amounts.

2. Consent to Receive Electronic Payments and Electronic Only Payment Remittance Advice. As applicable, you agree to

receive Electronic Payments and Electronic Only Payment Remittance Advices from all Payers, as defined below, consistent

with the features of the Optum Pay Services you acquired in the Subscription of your choice. You acknowledge that access to

Electronic Payment Remittance Advices may be provided to you via a link to a Payer’s online portal, a feature of the Optum

Pay Services you acquired in the Subscription of your choice, or via another means designated by a Payer.

ACH Payments.

This Agreement is subject to Article 4A of the Uniform Commercial Code (“UCC”). You hereby

authorize us, acting directly or indirectly on behalf of or through, any third party administrator, health care coalition,

health plan carrier, or other third party carrier or payer (each a “Third Party Payer”), or any individual consumer or other

4/2021

person (an “Individual Payer” and collectively “Payers”), to credit or debit your Account(s)

in connection with

processing transactions between you and any

Payers. You agree that we may rely upon all Account information and

identifying numbers provided by you on the Enrollment Agreement to receive Optum Pay Services.

We may rely on the

routing and account numbers you provided even if they identify a financial institution, person or account other

than

the one named on the Enrollment Agreement. You agree to comply with all applicable federal and state laws,

regulations, rules and guidelines related to electronic

funds transfers, including without limitation, Article 4A of the

UCC and the operating rules and regulations of the National Automated Clearinghouse Association. These rules

provide, among other things, that payments made to you, are provisional until final settlement is

made through a

Federal Reserve Bank or payment is otherwise made as provided in Article 4A-403(a) of the UCC. If we do not receive

good funds in connection with any

payment made to you, we are entitled to a refund from you in the amount

credited to your Account and the Payer that originated or instructed

such payment will not be considered to have paid

the amount so credited. In the event that we need to debit or credit your Accounts to make adjustments,

changes or corrections in accordance with the terms of this Agreement, we may do so immediately and

without prior notification.

Such adjustments, changes, or corrections may include, but are not limited to, reversing

an improper credit to your Account,

making adjustments for returned items, and correcting calculation and input

errors. Our right to make adjustments shall include the right to offset amounts you owe us or a Payer against future

amounts payable to you and shall not be subject to any limitations or time constraints, except as required by law.

Bank Accounts.

You represent and warrant that (i) you are the owner of each of the Accounts, or have been

delegated authority as an authorized user of the Accounts, or have authority to otherwise cause transactions on the

Accounts and (ii) none of the Accounts is or will

be used primarily for personal, family or household purposes. You

authorize Optum to make credits and debits on your Account(s) in accordance with this Agreement and this

authorization will remain in effect until we receive written notification from you of termination or change.

Disclosures of Information to others.

We may disclose information to Payers and third parties about you and

your Account(s) and transactions

as follows: (i) pursuant to agreements with Payers and other third parties that utilize

Optum Pay Services or assist us in the provision of Optum Pay Services; (ii) to verify the existence and condition of an

Account; (iii) as otherwise necessary for us to provide Optum Pay Services, including but not limited to, accurately

effectuating payments; (iv) as instructed by you; (v) in accordance with the Optum Financial, Inc. Website Privacy

Policy; and (vi) as otherwise required in response to a court order, subpoena, search warrant, law or regulation.

Virtual Payment Card; processing fees.

If you have elected to receive payments by prepaid virtual payment

(“Virtual Card”), you

agree: (i) that such election constitutes your consent for any Payers, including but not limited to,

Third Party Payers and Individual Payers, to make payments to you by Virtual Card; (ii) that mailing of the Virtual

Card

constitutes payment for purposes of a Payer’s compliance with applicable law; (iii) to only process Virtual Card

payments using your systems; and (iv) that use of the Virtual Card is subject to and you will comply with this

Agreement and the Virtual Card terms and conditions that

accompany the Virtual Card. You acknowledge that that

by processing a Virtual Card payment, you are subject to the terms and conditions governing card processing

between you and your card service processor and that you are responsible for any charges and related third party

fees, including interchange, merchant discount, or other card processing fees that may be imposed as a result of

processing a Virtual Card payment through a card processor.

7. Security. You are responsible under this Agreement for all use of the Optum Pay Services, including but not limited to, any

authorization, direction, action or failure to act by your designated contacts or any individual or entity authorized by you to transact

business or otherwise utilize Optum Pay Services, including to initiate payment of your Paid Subscription, on behalf of your

organization (an “Authorized User”), even if you did not intend for such use to occur. It is your sole responsibility for determining who

is an Authorized User, monitoring and auditing an Authorized User’s use of the Optum Pay Services, and for removing Authorized

Users in a timely manner. You authorize us to provide all information to any Authorized User and to discuss the Optum Pay Services

with them. Furthermore, you agree to notify each Authorized User, at the time he or she becomes an Authorized User, that we may

receive, record, exchange and use information about him or her in the same manner we do with information about you, as described

herein. You shall notify us immediately in writing if any Authorized User

is no longer authorized to transact business

or make changes on behalf of you or your organization. You agree that: (i) we may process all instructions related to

Optum Pay Services that are or appear to be submitted by an Authorized User and that such instructions are

effective even if not authorized by you; (ii) you will maintain appropriate accounting and auditing procedures to protect

your Account(s)

and Optum Pay Services

from misuse; and (iii) you will promptly review all electronic

statements, notices and transaction information made available to you and

you shall report all unauthorized transactions

and errors to us immediately. You are responsible for maintaining the security of your Accounts and any information related

to your Optum Pay Services, including the security of your computer equipment and Optum Pay account access passwords or

4/2021

credentials. We shall have no liability to you or any third-party in the event of a security incident, compromise or breach as a

result of or arising from the actions or omissions caused directly, or indirectly, by You, your Authorized Users, your agents or

employees.

8. Cooperation. If you report any unauthorized transaction on your Accounts or related to your Optum Pay Services, you agree

to cooperate with us in the investigation of the claim. This may include preparing an affidavit containing whatever information

we require concerning the Accounts or Optum Pay Services, the transaction, and the circumstances surrounding the loss.

9. Payer payment p riority; d isenrollment. If you have elected to receive payments by both ACH and by Virtual Card,

the default payment method will be ACH, unless you change your preferences using our Internet website. At any

time, you may dis-enroll from receiving electronic

payments: (i) from a specific Third Party Payer; or (ii) from one or more

Individual Payers by providing us with written notice that includes information reasonably requested by us. Upon request,

we will provide you with access to a form detailing the information we need from you to

process your dis-enrollment.

Dis-enrollment and changes to your payment method preferences will be effective thirty (30) days after receipt by us of

such notice or request.

10.

Ownership.

Except as provided in this Agreement, we own all rights, title and interests in the Optum Pay Services,

including but not limited to, any data and information

arising from or in connection therewith (“Data”). You hereby

acknowledge that you shall not acquire any ownership rights in the Optum Pay Services, including any Data by

virtue

of this Agreement.

Subject to the terms and conditions set forth in this Agreement, we hereby grant to you a limited, non-

exclusive, non-transferable license to access the Optum Pay Services, including any Subscription, and view Data through our

Internet Website (“Website”) while your Subscription remains active and in good standing.

The periods during which you can access Optum Pay Services and view certain Data will vary based on the rights available

for such Data and the terms of your Subscription. Any unauthorized use or copy of any element of the Optum Pay Services,

including the Data, underlying software, or any portion thereof will constitute a violation of our rights under this

Agreement. We may, in our sole discretion, and at any time, with or without notice, suspend, disable or terminate your

Subscription, and/or access to all or any part of the Optum Pay Services or any Data for any reason or no reason at all,

without liability. If we disable your Subscription, you agree that you will not create another enrollment or otherwise try to

access the Optum Pay Services without our permission. Violation of this Agreement in any manner automatically terminates

the license granted to you herein and obligates you to cease all use of the Optum Pay Services.

You may not reverse engineer, copy, decompile, disassemble, derive the source code of, modify, adapt, capture, reproduce,

publicly display, transfer, sell, license, create derivative works from or based upon, republish, edit, post, transmit, distribute,

exploit or circumvent (or attempt, or encourage or assist any other person, to do any of the foregoing), in whole or in part,

the Optum Pay Services or any Data.

11.

Warranties.

WE HEREBY DISCLAIM ALL WARRANTIES WITH RESPECT TO THE OPTUM PAY SERVICES PROVIDED

HEREUNDER, WHETHER EXPRESS, IMPLIED, STATUTORY OR OTHERWISE, INCLUDING WITHOUT LIMITATION ANY

WARRANTY OF MERCHANTABILITY OR FITNESS FOR USE

FOR A PARTICULAR PURPOSE.

12.

Indemnification.

You agree to indemnify, defend and hold us harmless from and against any and all losses,

liabilities, costs, damages and expenses, including litigation expenses and reasonable attorneys’ fees arising from or

incurred as the result of: (i) your breach of this Agreement; (ii) your unauthorized or unlawful use of the Optum Pay

Services; (iii) the unauthorized or unlawful use of the Optum Pay Services by

an Authorized User; (iv) any inaccurate

or incomplete data you provide or fail

to provide to us; (v) your failure to timely update information; or (vi) the

negligence or willful misconduct of you, your directors, officers,

employees, designees, agents, affiliates and

Authorized Users. You shall bear all risk of loss of records, data and materials during transit from you to us or

to our

agents or sub-contractors.

13.

Limitation of Liability. Under no circumstances shall our financial responsibility for any act or failure

to act by us under this

Agreement exceed the fees or charges paid by you to us (excluding the

portion of fees constituting pass through fees) for

the transaction or activity that is or was the

subject of the alleged failure of performance. In no event shall we, our parent, affiliates,

subsidiaries, directors, officers, employees, agents or representatives be liable for special incidental

or consequential damages or claims by you or any Payers or third party relative to the Optum Pay

Services provided hereunder. We do not guarantee the

payment or timing of payments. Payment is

the responsibility of the particular Payer. We will not be liable if circumstances beyond our control

4/2021

prevent a payment, despite reasonable precautions we have taken. Such circumstances include but

are not limited to, delays or losses of payments caused by telecommunications outages, actions of

third parties and equipment

failures. You agree that the foregoing limitation of liability is an agreed

upon allocation of risk between you and us and

reflects the fees, if any, we charge you to use the

Optum Pay Services. You acknowledge that absent your agreement to this

limitation of liability,

we would not provide the Optum Pay Services to you.

14.

Electronic communications; notice.

You hereby consent to receive all communications, including statements and

notifications related

to payment electronically through our Internet website. Any written notice required or permitted to

be given to you pursuant to this

Agreement may be provided to you at the email address provided by you to us during

the enrollment process. Any notice required or

permitted to be given to us pursuant hereto shall be provided in writing

to the following address: Optum Financial, Inc., P.O. Box 30777, Salt Lake City, UT 84130-0777. Written notices sent

by mail shall be delivered by registered or certified mail, return receipt requested, postage prepaid and shall be deemed

effective seventy-two (72) hours after the same is postmarked. Notice sent by

any other method shall be effective only

upon actual receipt.

15.

Amendments.

We may add, remove, change or otherwise modify any term of this Agreement at any time by

providing you with notice.

You agree that amendments may be provided in electronic form and will

be sent to your

primary user’s email address. We may also modify, terminate or discontinue some or all of the Optum Pay Services at

any time

and will provide notice of such changes only as required by applicable law.

16.

Entire agreement.

This Agreement, including the Enrollment Agreement and Website Terms, which are

incorporated herein as a part of this Agreement, constitutes the

only and entire agreement between the parties hereto

relating to the subject matter hereof and all prior negotiations, agreements and understandings relating to the subject

matter hereof, whether oral or written, are superseded or canceled hereby.

17.

Governing law and venue.

The laws of the State of Minnesota shall govern this Agreement and all disputes arising

hereunder or thereunder. You agree that jurisdiction and venue are proper in the State of Minnesota for the resolution

of any dispute arising under this Agreement.

18. Arbitration.

(i)

As permitted by applicable law, any claim or controversy that is not resolved informally by the us shall, at

the request of a party, be resolved by binding arbitration in accordance with the applicable commercial arbitration rules of

the American Arbitration Association, except to the extent modified by the Enrollment Agreement and this Agreement. In

no event may arbitration be initiated more than one year following the date the dispute arose. Any arbitration proceeding

under the Enrollment Agreement or this Agreement shall be conducted in Minneapolis, Minnesota. The arbitrator may

construe or interpret, but shall not vary or ignore the terms of this Agreement, and shall have no authority to award extra

contractual damages of any kind, including punitive or exemplary damages, and shall be bound by controlling law.

Judgment upon an arbitration award may be entered in any court of competent jurisdiction. The parties acknowledge that

because this Agreement, including the Enrollment Agreement and Website Terms affects interstate commerce, the Federal

Arbitration Act applies; and (ii) No dispute resolution proceeding between you and Optum shall be permitted to be

conducted in a class, representative, or private attorney general action, nor may any such proceeding be consolidated with

any other dispute. Optum and you agree that any claims related to the validity of this class waiver shall only be resolved by a

court of competent jurisdiction located in Minneapolis, Minnesota.

19.

Severability.

If any provision of this Agreement is found to be unenforceable according to its terms, all remaining

provisions will continue

in full force and effect.

20. Miscellaneous. The relationship between both parties under the Enrollment Agreement and this Agreement is

that of independent contractor. Nothing herein contained shall be construed as constituting a partnership, joint venture

or agency between the parties hereto. You shall not assign the Enrollment Agreement or this Agreement, directly or

by operation of law, without our prior written consent. Any attempted assignment without such consent shall be void.

waiver or failure to exercise any option, right, or privilege under the Enrollment Agreement or this Agreement

shall be construed to be a waiver of the same or any other option, right or privilege on any other occasion. You agree

to cooperate fully with us in furnishing any information, documentation or performing any action requested by us. You

shall furnish us, upon forty-eight (48) hours’ notice, with true, accurate and complete copies of such records,

documentation or any other information we or our authorized employees, representatives, agents and any regulatory

agencies may request; provided, however, that you shall not be required to divulge any records to the extent prohibited

by applicable law.

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