Direct Deposit Authorization

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Note: This form is completed when you would like to receive Direct Deposit reimbursement into your personal bank account when submitting for claims reimbursement.

** Indicates Required Fields.

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PLEASE READ AND INITIAL THE FOLLOWING STATEMENT

I hereby authorize IntegraFlex to initiate credit entries to my account as indicated below and the depository named below, hereinafter called DEPOSITORY, to credit the same to such account. I further authorize IntegraFlex to reverse any credit entry that IntegraFlex makes to my account to the extent that IntegraFlex reasonably believes such entry was made in error.

Account Information

Note: Please take great care to make sure when entering your Routing and Account numbers that you've entered them correctly. This information is extremely important when we go to Direct Deposit your reimbursement to the bank account you specify.

PLEASE READ AND INITIAL THE FOLLOWING STATEMENT

This authority is to remain in full force and effect until IntegraFlex has received written notification from me of its termination in such time and in such manner as to afford IntegraFlex and DEPOSITORY a reasonable opportunity to act on it. I understand this authorization is for reimbursements from my employer-sponsored Flexible Benefits and/or Health Reimbursement plan.

Employer Information
Employee Information

Note: Please provide us with your best contact number and email address, so we may contact you regarding your account, if needed.

Date of Signature

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