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Sale
Products & Services
Pharmacy
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Events
About
- Locations
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- Careers
Customer Service

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Automatic Withdrawals

Home

Customer Service

Authorization Form

What would you like to do today?(Required)

Set up a new monthly automatic withdrawal authorization

Make changes to an existing automatic withdrawal authorization

Cancel my automatic withdrawal authorization

Account Type(Required)

What type of account would you like funds withdrawn from?

Saving / Checking Account

Credit / Debit Card

Customer Information

Name(Required)

First Last

Resident's Date of Birth(Required)

Month

Day

Year

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Banking / Financial Institution Information

Name on Bank Account(Required)

Name of Bank/Financial Institution(Required)

Bank/Financial Institution Address(Required)

Street Address Address Line 2 City State ZIP Code

Data Security Notification

To ensure the protection of your personal financial information, we will not store or transmit your personal bank information online. To maintain security and confidentiality, we can record your account details over the phone.

Please have the following information prepared:

Account Type (Checking or Savings)
Bank Routing/ABA Number
Bank Account Number

How would you like to provide your bank information?(Required)

I would like Kohlls Rx to call me

I will call Kohlls Rx

Phone(Required)

What number should we call you at during our business hours of 8am-5pm?

Date(Required)

When is a convenient weekday to call you during our business hours of 8am-5pm?

MM slash DD slash YYYY

Time(Required)

When is a convenient time to call you during our business hours of 8am-5pm?

Hours

Minutes

AM/PM

Call-In Information

Our representatives are available between 8am-5pm, Monday through Friday.

Call Denise White, our Compliance Manager, at 402-973-1914.
or Call Julie Vanek at 402-306-6498.

Credit / Debit Card Information

Name on Credit Card(Required)

Data Security Notification

To ensure the protection of your personal financial information, we will not store or transmit your personal credit card data. To maintain security and confidentiality, we can record your account details over the phone.

Please have the following information prepared:

Card Type
Name on Credit Card
Card Number
Expiration Date (MM/YY)
CVC Security Code

How would you like to provide your credit card information?(Required)

I would like Kohlls Rx to call me

I will call Kohlls Rx

Phone(Required)

What number should we call you at during our business hours of 8am-5pm?

Date(Required)

When is a convenient weekday to call you during our business hours of 8am-5pm?

MM slash DD slash YYYY

Time(Required)

When is a convenient time to call you during our business hours of 8am-5pm?

Hours

Minutes

AM/PM

Call-In Information

Our representatives are available between 8am-5pm, Monday through Friday.

Call Denise White, our Compliance Manager, at 402-973-1914.
or Call Julie Vanek at 402-306-6498.

Additional Information

Who is completing this form?(Required)

Customer

POA/Payee

Statement delivery preference:(Required)

Mail statement to POA/Payee

Email statement to POA/Payee

Mail statement to resident at Ovation

POA/Payee Name(Required)

First Last

POA/Payee relationship to the Customer(Required)

POA/Payee Email(Required)

POA/Payee Phone(Required)

Authorization and Consent

Credit Card on File Agreement(Required)

I authorize and request SAKRX LLC, dba Kohll’s Rx, to charge my credit card for the prior month’s statement balance. Cards will be charged the first week of each month if a balance exists. My signature below authorizes Kohll’s to keep my credit card information securely on file. I authorize Kohll’s to charge my credit card for any outstanding balance when due.

If the credit card provided changes, expires, or is denied for any reason, I agree to immediately give Kohll’s Rx a new valid credit card. I agree the new card may be used with the same authorization as the original card I presented.

I agree to the Credit Card on File Agreement

Change Authorization Statement(Required)

I authorize and request Kohll’s Rx to make the changes indicated on this form for automatic withdrawals to my account.

I agree to the Change Authorization Statement

New Authorization Agreement(Required)

I authorize Kohll’s Rx to debit from the financial institution indicated above for withdrawal from my account for the prior month’s statement balance. I understand I may terminate this agreement at any time by completing another Customer Authorization form and sending it to Kohll’s Rx, 12741 Q Street, Omaha, NE 68137 and allowing a reasonable time for Kohll’s Rx to act upon my request for termination. I hereby authorize Kohll’s Rx to initiate debit entries and initiate, if necessary, credit entries and adjustments for any debit entries in error to my account as indicated above and depository named above to debit and/or credit the same to such account.

I agree to the New Authorization Agreement

Cancellation Statement(Required)

I request that Kohll’s Rx terminate my automatic withdrawal from my account. I will allow a reasonable time for Kohll’s Rx to act upon my request to terminate this agreement.

I agree to the Cancellation Statement

Signature(Required)

Signed: 04/29/2025

Name

This field is for validation purposes and should be left unchanged.

Automatic Withdrawals

Authorization Form

Customer Information

Banking / Financial Institution Information

Data Security Notification

Call-In Information

Credit / Debit Card Information

Data Security Notification

Call-In Information

Additional Information

Authorization and Consent

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