HEALTHCARE
FINANCE
DIRECT LLC.
UNDERSTANDING YOUR AGREEMENT
This addendum reflects the final pricing for your aligners.
Below you will see an addendum to your original agreement. The reason
we are sending you an addendum is to update the terms and conditions of
your SmilePay program as required by regulations. The terms and condi-
TM
tions of the original agreement were modified based on either a change in
your finance amount, the date of your first payment or the account you are
using to pay your monthly payments. We want you to understand your
agreement and are happy to help by answering any questions you may
have. Feel free to contact us should you need further information at
(800) 918-9018 or support@healthcarefinancedirect.com.
Remember you can always save by paying your account in full and you
can change your payment method by visiting our customer portal at
https://customer.healthcarefinancedirect.com.
ADDENDUM TO RETAIL INSTALLMENT CONTRACT
Patient/Borrower Information
Grace Ruebenacker
First Name Last Name MI
The purpose of this Addendum is to modify one or more terms or conditions of the RETAIL INSTALLMENT CREDIT SALE CONTRACT dated February 11 2023
____________________,_______
Creditor: SmileDirectClub 414 Union St. Suite 800 Nashville TN 37219
ANNUAL FINANCE Amount Total of Total Sale Price
PERCENTAGE CHARGE Financed Payments The total cost of your
RATE The total dollar The amount of credit The amount you will purchase on credit,
The cost of your amount the credit provided to you or on have paid after you including your down
credit as a yearly will cost you. your behalf. have made all payment
rate. payments as 250.00
of $_________
scheduled.
22.90% 513.33 1,800.00 2,313.33 2,563.33
Your payment schedule will be:
Number of Payments Amount of Payments When Payments Are Due
26 88.97 March 24, 2023
1,800.00
Itemization of the Amount Financed of $_________________
1,800.00
$__________________ Cash Price of Services
TERMS AND CONDITIONS
2023 for valuable consideration received, the undersigned Buyer and/or Co-Buyer (hereinafter
February 15 _______,
On this date of ____________________,
collectively referred to as “Buyer”), jointly and severally unconditionally promise(s) to pay for services provided by SmileDirectClub (“Provider”)
1,800.00
on behalf of its affiliates the sum of $_____________, 22.92
plus a finance charge at an annual rate of _________%. Payments are made to Healthcare
Finance Direct, LLC (“HFD”) as payment processor for SmileDirectClub. Your payment will appear on your statement as HFD-SmileDirectClub.
Monthly Payment Using Bank Account
Depository Institution:__________________________________ ABA Routing Number: __________________________________
Account Number: __________________________________
Monthly Payment Using Card
Card Type: Credit Debit HSA/FSA XXXXXXXXXXX5023
Card Number: ______________________________
Name on the Card: ________________________________________________
Healthcare Finance Direct, LLC
1201 24th Street, Suite B-200 Bakersfield, CA 93301
(800) 918-9018 / (661) 466-5333 (fax)
HEALTHCARE
FINANCE
DIRECT LLC.
ORIGINAL CONTRACT
Below is your original retail installment contract. The addendum
above supersedes information in agreement below. Please see
addendum above for payment plan details.
Feel free to contact us should you need further information at
(800) 918-9018 or support@healthcarefinancedirect.com.
RETAIL INSTALMENT CONTRACT
This is a consumer credit transaction –Subject to State Regulation
Buyer Copy
Buyer Information Co-Buyer Information (If Applicable)
Grace Ruebenacker
First Name Last Name MI First Name Last Name MI
82-44 63rd Avenue NEW YORK NY 11379
_______________________________________________________ _______________________________________________________
Present Address City State Zip Present Address City State Zip
19175898372
___________________ October 19, 1970
___________________ _______________ ___________________ ___________________ _______________
Primary Phone Number Work Number Date of Birth Primary Phone Number Work Number Date of Birth
***-**- Gzap143@aol.com
__________________________________ ***-**-_____________ __________________________________
Social Security Number E-mail Address Social Security Number E-mail Address
Creditor: SmileDirectClub 414 Union St. Suite 800 Nashville TN 37219
ANNUAL FINANCE Amount Total of Total Sale Price
PERCENTAGE CHARGE Financed Payments The total cost of your
RATE The total dollar The amount of credit The amount you will purchase on credit,
The cost of your amount the credit provided to you or on have paid after you including your down
credit as a yearly will cost you. your behalf. have made all payment
rate. payments as 250.00
of $_________
scheduled.
22.90% $ 513.33 $ 1,800.00 $ 2,313.33 $ 2,563.33
Your payment schedule will be:
Number of Payments Amount of Payments When Payments Are Due
26 $ 88.97 March 18, 2023
$
Prepayment: If you pay off early, you will not have to pay a penalty.
See your contract documents for any additional information about nonpayment, default, required repayments in full before the
scheduled date, and prepayment refunds and penalties.
1,800.00
Itemization of the Amount Financed of $_________________
1,800.00
$__________________ Cash Price of Services
Please review the Terms and Conditions prior to signing.
RETAIL INSTALLMENT CREDIT SALE CONTRACT (NY) PAGE 1 of 3
758-001 49621.2
TERMS AND CONDITIONS
February 11 2023
On this date of ________________________, _____, for valuable consideration received, the undersigned Buyer and/or Co-Buyer (hereinafter
collectively referred to as “Buyer”), jointly and severally unconditionally promise(s) to pay for services provided by
SmileDirectClub
________________________________________ 1,800.00
(“Provider”) on behalf of its affiliates the sum of $________________, plus a finance charge at
22.92
an annual rate of ____________%. Payments are made to Healthcare Finance Direct, LLC (“HFD”) as payment processor for Provider.
Monthly Payment Amounts. Buyer understands and agrees that he/she shall make monthly payments according to the payment schedule above.
Relationship of Parties. Buyer acknowledges and agrees that HFD is not a lender but rather the payment processing service provider of Provider.
Account Service Fees.
Returned Item Fee. In the event that a check or other form of payment is returned for insufficient funds, or for any other
Buyer Co-Buyer
Initials Initials reason, HFD will charge the Buyer a returned item fee of $20.
Monthly Statements. Buyer agrees that he/she will not receive a monthly statement, payments will be made via automatic withdrawal from Buyer’s
bank account, debit card or credit card, and these withdrawals will appear on Buyer’s bank, debit card or credit card statement. Written statements of
Buyer’s account balance can be provided upon written request.
Changes to this Contract. Any changes to this Contract, other than the amount owed, must be approved by and between the Buyer and Provider
and submitted to HFD in writing by Provider. No oral modifications will be effective or accepted. If there is a reduction to the amount owed under
this Contract, this will be made solely by notifying the Buyer of the reduction. If there is an increase to the amount owed under this Contract, this
will be made by obtaining the written consent of the Buyer and Provider using the Addendum form. It may take as many as 5 days for such changes
to take effect. While modifications are being processed, the Buyer will remain responsible for any charges under this Contract.
Assignment. Buyer agrees that he/she shall not assign or transfer his/her rights or obligations under this Contract. Buyer agrees that Provider may
assign its rights under this Contract at any time and any assignment shall be binding and inure to the benefit of all of the respective legal
representatives, successors and assigns.
Notice to the Assignee. The assignee receiving or acquiring this Contract shall be subject, under equal conditions, to any claim or defense that the
Buyer may initiate against the Creditor. The assignee of the Contract shall be entitled to file against the Creditor all the claims and defenses that the
Buyer may raise against the Creditor of the goods and the services.
No Prepayment Penalty. Buyer understands that the obligations under this Contract may be prepaid in whole or in part at any time, without
premium or penalty. Buyer may contact HFD at 800-918-9018 or 1201 24th Street, Suite #B-200, Bakersfield CA, 93301, to obtain a current
statement of the balance that is due and owing.
Default by Buyer. Subject to any requirements or restrictions of applicable law: (i) the breach of any term of this Contract by Buyer, (ii) the
cancellation of Buyer’s automatic monthly payment authorization and failure to substitute another form of payment, or (iii) the failure to make any
payment in full or on a timely basis as required herein, shall constitute a default. Upon such default the entire unpaid balance shall become
immediately due and payable; Subject to any requirements or restrictions of applicable law, Buyer agrees to pay all costs and expenses incurred by
HFD and/or Provider as the result of such default, including costs and expenses of collection (including without limitation the costs of HFD servicing
on behalf of Provider) and reasonable attorneys’ fees.
Governing Law. The validity, interpretation, and enforcement of this Contract and its terms and conditions shall be interpreted and governed under
the laws of the State of New York.
ANY HOLDER OF THIS CONSUMER CREDIT CONTRACT IS SUBJECT TO ALL CLAIMS AND DEFENSES WHICH
THE DEBTOR COULD ASSERT AGAINST THE SELLER OF GOODS OR SERVICES OBTAINED PURSUANT
HERETO OR WITH THE PROCEEDS HEREOF. RECOVERY HEREUNDER BY THE DEBTOR SHALL NOT EXCEED
AMOUNTS PAID BY THE DEBTOR HEREUNDER.
NOTICE TO THE BUYER: 1. Do not sign this agreement before you read it or if it contains any blank space. 2. You are
entitled to a completely filled in copy of this agreement. 3. Under the law, you have the right to pay off in advance the full
amount due. If you do so, you may, depending on the nature of the credit service charge, either: (a) prepay without penalty, or
(b) under certain circumstances obtain a rebate of the credit service charge.
RETAIL INSTALLMENT CREDIT SALE CONTRACT (NY) PAGE 2 of 3
758-001 49621.2
I/We have reviewed the Terms and Conditions of this Contract. I/we understand that I/we am/are responsible for payment of any and all obligations
under this Contract, and agree to the Terms and Conditions of this Contract.
RETAIL INSTALMENT CONTRACT
February 11 _____
Buyer Signature: ________________________________________________ Date: ________________________, 2023
Co-Buyer Signature:______________________________________________ Date: ________________________, _____
Monthly Payment Using Bank Account
Buyer authorizes HFD to initiate debit entries via the Automated Clearing House (“ACH”) network or Debit Card for the checking account or
savings account at the bank that Buyer has provided on this form. This authorization permits HFD on behalf of Provider to charge the Monthly
Payment Owed, any late fees, or returned item fees, as reflected on this Contract. Buyer understands that Buyer has a right to receive written notice
of all varying transfers at least 10 days before the scheduled date of transfer. However, by signing below Buyer agrees that Buyer will only receive
such notice if a transferred amount will be more than 25% greater than the amount of the immediately preceding transfer. Buyer also authorizes HFD
to resubmit any failed debit entry up to two (2) additional times prior to the next payment date. The authorization for debit entries shall remain in
effect until Buyer has canceled it. To stop a payment, Buyer must contact HFD in time for HFD to receive the request 7 business days or more
before the payment is scheduled to be made. If Buyer calls, HFD may also require Buyer to put Buyer’s request in writing and get it to HFD within
14 days after Buyer’s call. Buyer understands and acknowledges that Buyer may terminate this authorization by notifying HFD in such time and
manner as to afford HFD and the bank specified below a reasonable opportunity to act on it. Buyer understands and agrees that, in the event of any
returned item or failed debit entry, HFD will charge Buyer a Returned Item Fee of $20 on his/her next monthly payment, in addition to a Late Fee of
[insert contract rate]% of installment (maximum $25). For any returned item, HFD will also have the right to charge fees from the additional account
listed below. Buyer also understands that his/her bank may charge a fee for a returned item.
Depository Institution:___________________________________ ABA Routing Number: ___________________________________
Account Number:
City, State, Zip: ______________________________________ Account Number: _______________________________________
Account Type: Checking Savings
Debit Card Type: Visa MasterCard Card Number: ______________________________________________________
Name on the Card: ________________________________________________
Monthly Payment Using Credit Card
Buyer authorizes HFD on behalf of Providerto directly charge the Monthly Payment owed, any late fees, or returned item fees on the credit card
Buyer has provided. This authorization will remain in effect until Buyer has canceled it. Buyer understands and agrees that, in the event of any
returned item or failed debit entry, HFD will charge Buyer a Returned Item Fee of $20 on his/her next monthly payment, in addition to a Late Fee of
[insert contract rate]% of installment (maximum $25). For any returned item, HFD will also have the right to charge fees from any additional
account listed above. Buyer also understands that his/her credit card company may charge a fee for a returned item.
Credit Card Type: Visa MasterCard Discover AMEX Account Number: ______________________________
Name on the Card: ________________________________________________
You must ACCEPT below to authorize automatic ongoing payments.
Buyer Signature: _____________________________________________________ February 11 _____
Date: ________________________, 2023
Co-Buyer Signature:___________________________________________________ Date: ________________________, _____
RETAIL INSTALLMENT CREDIT SALE CONTRACT (NY) PAGE 3 of 3
758-001 49621.2
