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Get HealthSCOPE Benefits Direct Deposit Authorization Form

HealthSCOPE Benefits Flexible Spending Account Direct Deposit Authorization Form Please complete and sign for convenient Automatic Deposit Option with E-mail Notifications. Please note that an Email address is required to enroll in Automatic Deposit Employee Name Employee SSN Address City State Zip SIGNATURE E-mail address You may attach a voided check or fill in the information below. Please check closely for accuracy. Bank Routing Number 9 digits Bank Account Number RETURN TO FAX 501 225-9153 or mail to PO Box 350 Little Rock AR 72203. Please note that an Email address is required to enroll in Automatic Deposit Employee Name Employee SSN Address City State Zip SIGNATURE E-mail address You may attach a voided check or fill in the information below. Please check closely for accuracy. Bank Routing Number 9 digits Bank Account Number RETURN TO FAX 501 225-9153 or mail to PO Box 350 Little Rock AR 72203. .

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