Direct Deposit Form
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1F
S
A
LEXIBLE
PENDING
CCOUNT
P
R
ARKING
EIMBURSEMENT
D
D
F
IRECT
EPOSIT
ORM
EMPLOYEE INFORMATION
(Please Print)
Employer:
Employee Name:
Employee Social Security Number:
Address:
City:
State:
Zip:
Email Address:
I wish to receive my flexible spending account and/or parking reimbursements by Direct
Deposit. I hereby authorize Health Economics Group, Inc. (HEG) to originate electronic
credit transactions to my bank (or credit union or savings & loan) account indicated
below and to credit the same to such account. If necessary, HEG may make deductions
from my account for any payments credited to my account in error. This authority is to
remain in full force and effect until HEG has received written notification from me of its
termination in such time as to afford HEG and my bank a reasonable opportunity to act
on it.
Please note: if you elect the direct deposit option for receiving your payment of flexible
benefits and/or parking claims, you will receive a summary of your claims submitted
every 90 days instead of an “explanation of benefits” at the time of each deposit.
BANK INFORMATION
(Please Print)
Bank:
Routing Number:
Account Number:
Type:
Checking
Savings
Is this a change to a current authorization?
Yes
No
Signature: ___________________________________________
Date:___________
D
D
A
V
IRECT
EPOSIT
CCOUNT
ERIFICATION
Please attach a void check or deposit slip in this area so that we may verify your routing and account numbers.
Health Economics Group, Inc.
1050 University Avenue, Suite A
Rochester, NY 14607
(585) 241-9500 / (800) 666-6690
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