Fillable Printable Direct Deposit Application Form - Missouri

Direct Deposit Application Form - Missouri

MISSOURI DEPARTMENT OF SOCIAL SERVICES

MO HEALTHNET DIVISION

HEALTH INSURANCE PRE MIUM PAYMENT PROGRAM

DIRECT DEPOSIT APPLICATION

PLEASE TYPE OR PRINT IN BLACK INK SEE INSTRUCTIONS ON PAGE 2

SECTION A (PLACE A CHECK IN THE BOX OF YOUR CHOICE)

 START I request that the Missouri Department of Social Services, MO HealthNet Division deposit my Health Insurance Premium

Payment Reimbursement to my bank account. I authorize my financial institution to credit the deposits to the account

named below. (See Section B)

 CHANGE I request that the Missouri D epartment of Social Serv ices, M O HealthN et Division change my direct deposit to the bank

account named below. I authorize my financial institution to credit the deposits to the account named below. (See Section

 CANCEL I request that the Missouri Department of Social Services, MO HealthNet Division cancel direct deposit of my Health

Insurance Premium Payment Reimbursements to my bank account.

SECTION B (COMPLET E WITH YOUR BANK INFORMATION)

(A VOIDED CHECK SHOWING THE ROUTING AND ACCOUNT NUMBE RS MUST BE ATTACHED)

NAME OF FINANCIAL INSTITUTION TELEPHONE NUMBER (INCLUDE AREA CODE)

ADDRESS (CI TY, STATE, ZI P CODE)

ROUTING NUMBER ACCOUNT NUMBER (  CHECKING  S AVINGS )

NAME SOCI AL SECURITY NUMBER

SECTION C

I wi s h to participate in Direct Deposit and in doing so:

• I understand that in endorsing or depositing checks that payment will be from Federal and State funds and that any falsification, or

concealment of material fact, may be prosecuted under Federal and State laws.

• I hereby authorize the S tate of M issouri to initiate credit entries (deposits) and to initiate, if necessary, debit entries (w ithdraw als) or

adjustments for any credit entries made in error to my account designated above.

• I understand that the State of M issouri may ter minate my enrollment in the Direct D eposit progr am if the St ate is legally obligated to

withhold part of all payments for any reason.

• I understand that the State of Missouri may terminate my enrollment if I no longer meet the eligibility requirements.

SIGNATURE DATE TELE P HONE NUMBER (I NCLUDING AREA CO DE )

RETURN THIS FORM AND VOIDED CHECK TO:

MO HEALTHNET DIVISION

THIRD PARTY LIABILITY UNIT, ATTN: HIPP

P.O. BOX 6500

JEFFERSON CITY, MO 65102

MO866-3766 (1-01) Page 1

INSTRUCTIONS FOR COMPL E TING THE APPLICATION FOR DIRECT DE P OSI T

SECTION A

 START Check this box if y ou ar e currently on the H IPP progr am, or are a new participant with the H IP P Program and w ant the

HIPP Program to direct deposit your reimbursement directly into y our bank account. T his process w ill take at least 10

days to verify your bank account. Any reimbursements made before the bank verifies your account will be by check and

mailed directly to you.

 CHANGE Check this box if you are currently enrolled with the Direct Deposit, and need to close the bank account where you

currently have reimbursements deposited and want the reimbursements deposited in a newly opened bank account. This

re-

verification of the new bank account will cause a delay in your reimbursement of approximately 10 days. Complete the

form with the new account information. DO NOT CLOSE AN OLD ACCOUNT UNTIL THE FIRST PAYMENT IS

DEPOSITED INTO YOUR NEW A CCOUNT.

 CANCEL Check this box if you are currently enrolled wi th Direct Deposit and want to cancel Direct Deposit reimbursements. If

you are currently active with the HIPP program, by c anceling the Direct Deposit your reimbursements will be by a

check mailed directly to you.

SECTION B

Complete this information and attach a VOIDED copy of a check. Include your bank’s name, address, and phone number. The electronic

routing number of your financial institution is printed on the bottom left portion of your check. Your account number is also located on the

bottom of your check. This is the series of digits after the routing number follow ed by your check number. Please print y our name and

include the Social Security Number of the Policyholder.

If you have any questions on this section, you may call your bank. Please remember to attach a copy of a check marked VOID across the

front of the check.

EXAMPLE

SECTION C

Read this agreement carefully, place y our Signature on the f orm and return this form w ith your ORIGINAL SIGNATURE to the address

listed on page 1.

OTHER

1. Attach a VOIDED CHECK to the front of the form w ithin the Section B. T his is necessary t o verify your depositor account number,

routing number and financial institution.

2. Direct deposit will be initiated after a properly completed application form is approved by the MO HealthNet Division and the

success ful processing of a test transaction through the banking system.

3. This form MUST be us ed to change any financial institution information OR to cancel your election to participate.

4. If any information completed on this form cannot be verified from the attachments or the form is completed incorrectly, the form(s) will

be returned without being processed for direct deposit.

MO866-3766 (1-01) Page 2

POLICYHOLDER'S NA M E CHE CK NO. 4444

ADDRESS

PAY TO THE ORDER OF

____________________________

FINANCIAL INSTITUTION

CITY , STATE, ZIP

XXXXXXXXXXXXXXXXXX X XXXXXX XXXXX XXXXXX 4444

ROUTING NUMB E R DE P OSITOR ACCT NO. CHECK NO.