Direct Deposit Application printable pdf download

MISSOURI DEPARTMENT OF SOCIAL SERVICES

MO HEALTHNET DIVISION

HEALTH INSURANCE PREMIUM 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 Department of Social Services, MO HealthNet 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 (COMPLETE WITH YOUR BANK INFORMATION)

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

NAME OF FINANCIAL INSTITUTION

TELEPHONE NUMBER (INCLUDE AREA CODE)

ADDRESS (CITY, STATE, ZIP CODE)

CHECKING

S AVING S )

ROUTING NUMBER

ACCOUNT NUMBER (

NAME

SOCIAL SECURITY NUMBER

SECTION C

I wish 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 State of Missouri to initiate credit entries (deposits) and to initiate, if necessary, debit entries (withdrawals) or

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

•

I understand that the State of Missouri may terminate my enrollment in the Direct Deposit program if the State 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

TELEPHONE NUMBER (INCLUDING AREA CODE)

RETURN THIS FORM AND VOIDED CHECK TO:

MO HEALTHNET DIVISION

THIRD PARTY LIABILITY UNIT, ATTN: HIPP

P.O. BOX 6500

JEFFERSON CITY, MO 65102

Page 1

MO866-3766 (1-01)

Direct Deposit Application

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