Direct Deposit Application (Page 2 of 2) in pdf

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR DIRECT DEPOSIT

SECTION A



START

Check this box if you are currently on the HIPP program, or are a new participant with the HIPP Program and want the

HIPP Program to direct deposit your reimbursement directly into your bank account. This process will 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 ACCOUNT.



CANCEL

Check this box if you are currently enrolled with Direct Deposit and want to cancel Direct Deposit reimbursements. If

you are currently active with the HIPP program, by canceling 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 followed by your check number. Please print your 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

POLICYHOLDER'S NAME

CHECK NO. 4444

ADDRESS

PAY TO THE ORDER OF

____________________________

FINANCIAL INSTITUTION

CITY, STATE, ZIP

XXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX

4444

ROUTING NUMBER

DEPOSITOR ACCT NO.

CHECK NO.

SECTION C

Read this agreement carefully, place your Signature on the form and return this form with your ORIGINAL SIGNATURE to the address

listed on page 1.

OTHER

Attach a VOIDED CHECK to the front of the form within the Section B. This is necessary to verify your depositor account number,

routing number and financial institution.

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

successful processing of a test transaction through the banking system.

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

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.

Page 2

MO866-3766 (1-01)

Direct Deposit Application Page 2

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