Fillable Form 6252 Electronic Funds Transfer (Eft) Enrolled User Enrollment Form printable pdf download

Form 6252 Electronic Funds Transfer (Eft) Enrolled User Enrollment Form

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State of California

Department of Health Care Services

Health and Human Services Agency

Electronic Funds Transfer (EFT)

Enrolled User Enrollment Form

Section I- General Information (Refer to the instructions on page 2)

A. Program Name:

B. DHCS Account:

C. Beneficiary/ Provider/ Attorney/ Case Name:

D. Mailing Address: (Number, Street, City, State, Zip code)

E. Email Address: (Review for accuracy)

Re-type Email Address:

F. Payment Contact Person:

G. Phone Number: (xxx) xxx-xxxx

(Required for Providers and Law Offices)

Notice: This document is for DHCS internal use only and will not be shared with other entities.

Information provided in this section will only be used for account validation and enrollment in the

EFT Enrolled User option by DHCS staff and its authorized financial institution.

By providing your email address you agree to receive and accept communications regarding EFT

via email.

Section II- Authorization

Please read the following Authorization Agreement:

Automated Clearing House (ACH) Debit- I hereby authorize designated Financial Agents of the

Department of Health Care Services (DHCS), Third Party Liability and Recovery Division (TPLRD) to

initiate debit entries to the financial institution account that I saved in my Enrolled User Account, for

payments owed to the DHCS/TPLRD upon my request (beneficiary/ provider) or my representative,

using ACH debit method.

 I authorize the disclosure of my individually identifiable information as described above for the purpose

described.

 If I sign this authorization to use or disclose information, I can revoke that authorization at any time, in

writing. The revocation will not affect information already used or disclosed.

 I have the right to receive a copy of this enrollment form.

 I am signing this authorization voluntarily. Treatment, payment or my eligibility for benefits will not be

affected if I do not sign this authorization.

 I understand that a person to whom records and information are disclosed pursuant to this

authorization may not further use or disclose the information unless another authorization is obtained

from me or unless such disclosure is specifically required or permitted by law.

 I agree to receive EFT account correspondence via the contact information that I provided on this form.

 I hereby certify that the information given by me in this EFT Enrollment Form is true and correct.

 I understand and agree that any false information or misrepresentation of facts may be a justification

for refusal of enrollment to the EFT Enrolled User option.

A. Beneficiary/ Provider Representative/ Contact Signature

B. Date

DHCS 6252 (Rev 06/16)

Page 1 of 2

Form 6252 Electronic Funds Transfer (Eft) Enrolled User Enrollment Form

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