Fillable Printable Direct Deposit Authorization Agreement - Alabama

Direct Deposit Authorization Agreement - Alabama

All Coverage

Health, Dental and Drug

Preferred Blue Account (FSA, HRA, DCAP)

Blue Cross and Blue Shield of Alabama is pleased to offer the added convenience and security of direct deposit

at NO cost to you. To take advantage of Blue Cross’ Direct Deposit Service, all you need to do is:

• Complete the authorization form in full

•Provide a cancelled or voided check

• Return it to Blue Cross and Blue Shield of Alabama or enter online at www.bcbsal.com. For online access, click

“myBlueCross”. If you are not already registered, please click “Register Now” and follow the easy instructions.

TREASURY OPERATIONS

DIRECT DEPOSIT

AUTHORIZATION AGREEMENT

An Independent Licensee of the Blue Cross and Blue Shield Association

SUBSCRIBER NAME:

CONTRACT NUMBER(S):

DAY TIME PHONE NUMBER:

NAME ON ACCOUNT:

DEPOSITORY (BANK) NAME:

ABA ROUTING #:

ACCOUNT NUMBER:

(Please attach an original or copy of a voided check)

I hereby authorize Blue Cross and Blue Shield of Alabama to initiate credit entries (deposits) to my:

Checking Account Savings Account

at the depository (bank) named below (hereinafter called Depository Bank), and to credit the same to such account.

NOTE: Initial updates or changes will require a one week set-up period with the bank.

Please submit your request for reimbursement as usual. Once processed, all direct deposits will be reflected

on your bank statement. In addition, you will receive a “Statement of Account” and/or Claims Summary from

Blue Cross indicating the amount deposited in your specified account.

This authority is to remain in full force and effect until Blue Cross and Blue Shield of Alabama has received written notification

from me of its termination in such time and in such manner as to afford Blue Cross and Blue Shield of Alabama and DEPOSITORY

(Bank) a reasonable opportunity to act on said notification of termination. Blue Cross and Blue Shield of Alabama reserves the right to

return or adjust any errors in accordance with applicable National Automated Clearinghouse Association Operating Rules.

Signature Date

Please return this form and voided check to: Blue Cross and Blue Shield of Alabama

ATTN: Treasury Operations

450 Riverchase Parkway East

Birmingham, AL 35244-2858

— OR —

you may FAX this form and voided check to: Treasury Operations, FAX # (205) 220-2795.

ACT-18 (Rev. 06-2011)

ADD

CANCEL

CHANGE

CHECK ONE:

ACTION: