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Get Wsib Direct Deposit Form

Direct Deposit Enrollment Authorization For Healthcare/Non-Healthcare Providers Please return signed form to Fax 1-866-840-1466 Direct Enquires to TELUS Health Registration Line 1-866-240-7492 option 1 OR Mail to Provider Services Dept. - TELUS Health 1000-5090 Explorer Drive Mississauga ON L4W 4X6 Legal Registered Name WSIB /TELUS Health Provider No. Address Tel. No. Fax No. City/ Province/ Postal Code Email for confirmation of bank account changes Contact Effective Date Banking Information Bank Name Bank No. Transit No. City Prov. P. C. Account No. Phone Fax Please sign this form before returning to TELUS Health By signing this form you the undersigned authorize TELUS Health to change your profile including your bank account information. WSIBdirect-deposit-enrollment-authorization-providers-wsib-23/10/12 Signature of Provider Print Name Title Date Signature of Clinic Owner If this request is from a provider who is switching i from a shared clinic bank account to an individual account ii from an individual account to a shared clinic bank account or iii to a bank account not under the clinic owner name or provider name an authorizing signature of the clinic owner is required on the form before any changes can be made. Affix Pre-Printed void cheque here If the cheque is not pre-printed with either legal or operating name then a signed letter from your bank confirming the name and the account number with the name of the signing officers is required. Please ensure that you are receiving direct deposits into your new bank account before closing your old bank account. Direct Deposit Enrollment Authorization For Healthcare/Non-Healthcare Providers Please return signed form to Fax 1-866-840-1466 Direct Enquires to TELUS Health Registration Line 1-866-240-7492 option 1 OR Mail to Provider Services Dept. - TELUS Health 1000-5090 Explorer Drive Mississauga ON L4W 4X6 Legal Registered Name WSIB /TELUS Health Provider No* Address Tel* No* Fax No* City/ Province/ Postal Code Email for confirmation of bank account changes Contact Effective Date Banking Information Bank Name Bank No* Transit No* City Prov* P. C. Account No* Phone Fax Please sign this form before returning to TELUS Health By signing this form you the undersigned authorize TELUS Health to change your profile including your bank account information* WSIBdirect-deposit-enrollment-authorization-providers-wsib-23/10/12 Signature of Provider Print Name Title Date Signature of Clinic Owner If this request is from a provider who is switching i from a shared clinic bank account to an individual account ii from an individual account to a shared clinic bank account or iii to a bank account not under the clinic owner name or provider name an authorizing signature of the clinic owner is required on the form before any changes can be made. Affix Pre-Printed void cheque here If the cheque is not pre-printed with either legal or operating name then a signed letter from your bank confirming the name and the account number with the name of the signing officers is required* Please ensure that you are receiving direct deposits into your new bank account before closing your old bank account.

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