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Flexible Spending Accounts Direct Deposit Form

Flexible Spending Accounts Direct Deposit Form

 

INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNTS DIRECT DEPOSIT AUTHORIZATION FORM
 
Alabama public employees who are enrolled in the state PEEHIP health insurance plan and have a flexible spending account within this plan can use the form discussed in this article to obtain a direct deposit refund from their flexible spending account. This document can be obtained from the website maintained by the Retirement Systems of Alabama.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 1: Indicate with a check mark whether this pertains to a health policy, a dental policy, or a preferred blue account (FSA, HRA, DCAP).
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 2: Indicate with a check mark whether you wish to add, cancel or change.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 3: On the first blank line, enter the name of the subscriber.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 4: On the second blank line, enter the applicable contract number or numbers.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 5: On the third blank line, enter your daytime phone number, including the area code.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 6: Indicate with a check mark whether you authorize Blue Cross and Blue Shield of Alabama to make a direct deposit to your checking account, savings account or both.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 7: On the fourth blank line, enter the name on the account or accounts in question.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 8: On the fifth blank line, enter the name of the bank.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 9: On the sixth blank line, enter the ABA routing number of the accounts.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 10: On the seventh blank line, enter the account number in question.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 10: Attach a voided check, either in its original form or as a copy.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 11: At the bottom of the page, provide your signature and the date.
 
Flexible Spending Accounts Direct Deposit Authorization Form Step 12: Mail the form along with the voided check to the address given at the bottom of the page. You may alternately fax these documents to the number given at the bottom of the page.
 

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