Get The Health Plan Direct Deposit Authorization Form - Healthplan

Filling out the Health Plan Direct Deposit Authorization Form is a crucial step in ensuring timely payments to your designated bank account. This user-friendly guide will walk you through each section of the form, offering clear instructions to assist you in completing it accurately online.

Follow the steps to complete the form effectively.

1. Press the 'Get Form' button to retrieve the form and open it in your preferred online editor.
2. Identify the 'Provider Name (Legal Entity)' section. Enter the official name of the organization, ensuring it is spelled correctly as it appears in official documents.
3. Locate the 'Tax Identification Number' field. Input the provider's tax identification number, which is essential for tax reporting purposes.
4. In the 'Provider Billing Address' section, fill out the complete address, including street, city, state, and zip code where bills will be sent.
5. Complete the 'Contact Name' field with the name of the person responsible for managing the account.
6. Add the 'Telephone' number of the contact person, ensuring to include area codes.
7. Choose whether this submission is a 'Cancellation,' 'New Enrollment,' or 'Change' by circling the appropriate option.
8. Fill in the 'Bank Routing Number' and 'Bank Account Number' using the details provided by your financial institution.
9. Enter the 'Bank Account Name' associated with the routing and account numbers provided above.
10. Specify the account type by circling 'Business Checking Account,' 'Business Savings Account,' or 'Other' as appropriate.
11. Include the name and address of the bank. This information helps confirm the banking institution where the funds will be deposited.
12. Sign the form in the 'Authorization Signature' section, ensuring your signature matches any official documents for consistency.
13. Print your name and title, along with the date of signing, to verify who authorized the form.
14. After filling out all sections, save your changes, download a copy for your records, print for physical submission, or share the completed form as necessary.

Complete your documents online today to ensure quick and secure transactions.