4 - Team Cuban Card - Electronic ACH/Debit/Funds Transfer Questions 01/08/2024

This form and your responses to the questions therein concern ACH Debit/Funds Transfers that will take place in connection with your participation in the Cuban Pharmacy Affiliate Network and the Team Cuban Card program. Upon completion of the form, this document shall constitute an Addendum to, and shall be deemed incorporated into your CPD Affiliate Network Participation Agreement (the “Agreement”), pursuant to which your pharmacy has become part of the Cuban Pharmacy Affiliate Network. This form is secure. The form is designed to be completed separately for each pharmacy. If you are completing this form on behalf of 7 or more pharmacies, please contact us directly to arrange for an excel spreadsheet upload.
‍PLEASE NOTE:

‍1. By completing and submitting this form, you authorize Mark Cuban Cost Plus Drug Company, PBC, Mark Cuban Cost Plus Benefits, LLC, (collectively, “MCCPDC”) and our third party service provider partners—RevSpring, Inc., Loyale Healthcare, LLC, and any of our 3rd party payment processor partners (“Authorized Parties”)—to pay to MCCPDC all amounts payable by the named pharmacy to MCCPDC under the Agreement via ACH electronic funds transfer from the designated account using the information you include below. SUCH PAYMENTS SHALL INCLUDE, any fees that may be assessed from time to time in connection with such transactions, including, but not limited to, late fees (if the account has insufficient funds or if MCCPDC is otherwise unable to obtain payment from the designated account); and other fees incurred by MCCPDC in connection with such transactions including but not limited to ACH fees; transaction fees, refund fees, return fees, chargeback fees, fines, penalties, insufficient funds fees, or charges assessed by the Payment Networks as a result of violation of Payment Network Rules that pertain to MCCPDC's 3rd party merchant services provider’s (currently, Loyale Healthcare LLC rules and regulations). You acknowledge that a portion of the funds you collect from pharmacy customers who use the Team Cuban Card to make prescription drug purchases are property of MCCPDC and shall be held by you in the designated account for direct ACH debit in accordance with this agreement. In the event that any ACH debit results in an overdraft, or is denied due to insufficient funds, you will be responsible for any late fees payable pursuant to the Agreement as well as any transaction fees incurred by MCCPDC as a result thereof. Your bank also has the right to charge you additionally for overdraft fees, if applicable.

2. By completing and submitting this form, you also authorize the Authorized Parties to credit the designated account for any amounts due and owing to the pharmacy by MCCPDC pursuant to the Agreement, or to correct an erroneous debit from the account.

3. You must complete this form for each pharmacy that is subject to your Agreement and which you would like to have participate in the Cuban Network UNLESS all are in a central bank account for your pharmacies as a chain.

4. When completing this form, You cannot store and save information before submitting the form. We suggest you print out the form, collect your responses, and complete it in one session.

1. Please provide your first and last name:2. Please provide the name of your pharmacy:3. Please provide the NPI of your pharmacy: (If you have more than one pharmacy, please submit each pharmacy information separately - one pharmacy per ACH form.)4. Please provide your Financial Institution Name:5. Bank Branch Number (if applicable):6. Account Number at your Financial Institution:7. Routing Number:8. If you have a separate account for paying versus receipt of payment, please list the routing number below:9. If you have a separate account for paying versus receipt of payment, please list the account number at your financial institution below:10. Pharmacy Contact Name for Billing:11. Title of Pharmacy Contact Name for Billing:12. Phone Number of Pharmacy Contact for Billing: (Please format ###-###-####)13. Email address of Pharmacy Contact for Billing:14. Email address for 835 Files or Secured Documents for Billing:15. *By Signing below, you hereby represent that you are authorized to sign this form on behalf of the applicable pharmacy, and you hereby authorize Mark Cuban Cost Plus Benefits, LLC (and or its designee) to electronically debit the pharmacy’s designated account (and, if necessary, electronically credit Pharmacy's account, and to electronically credit pharmacy's account (and, if necessary, to electronically debit Pharmacy's account to correct erroneous credits), in accordance with the terms of the Mark Cuban Cost Program Participation Agreement entered into between the named pharmacy and Mark Cuban Cost Plus Drug Company, PBC.

SIGNATURE BELOW:16. Date of Signature: (Please input date MM/DD/YYYY)

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