Dhhs Form 2637 – Fill Out and Use This PDF

STATE OF NEW HAMPSHIRE – DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIRECT DEPOSIT/ELECTRONIC FUNDS TRANSFER (EFT)

AUTHORIZATION AGREEMENT

Enrolled Providers for the Division for Children, Youth and Families (DCYF)

INSTRUCTIONS

To enroll for Direct Deposit, please read the instructions on the reverse side of this form and fill in the information requested in sections 1 and

2.In order to process your request for EFT, a copy of a voided check or savings deposit slip must be attached to this form. Mail the original form to:

Department of Health and Human Services

Division for Children, Youth and Families – Provider Relations

129 Pleasant Street

Concord NH 03301

IMPORTANT: For each payment, it is your responsibility to verify that the amount listed on your Remittance Advice has been deposited into your bank account. The Remittance Advice does not guarantee that the money has been deposited. The Department of Health and Human Services is not responsible for any fees you incur from your bank.

SECTION 1

TELEPHONE NUMBER

I certify that I have read and understand the information on the reverse side of this form (or page 2 if internet version). In signing this form, I authorize my payment to be sent to the designated account. I also authorize the Department of Health and Human Services to adjust any deposit made in error and to deduct the amount of the error from my account or future payments.

SECTION 2

SECTION 3 (STATE OFFICE USE ONLY)

The information on this form will be used to process payment data from the Department of Health and Human Services to the bank and/or its agent. Failure to provide the requested information will affect the processing of this form and will delay or prevent the receipt of payments through Direct Deposit.

ACCESS TO ACCOUNT

Once the direct deposit is completed, any questions regarding access to funds are between the payee and the bank. All inquiries and liabilities regarding access to funds must be addressed to the bank. DHHS is not responsible for any fees charged to you by your bank.

CANCELLATION

The agreement represented by this authorization remains in effect until cancelled by the recipient by written notice using this form to the Department of Health and Human Services or by death or legal incapacity of the recipient. Upon cancellation by the recipient, the recipient should notify the receiving bank that she/he is doing so. The agreement is deemed to be cancelled upon closing your bank account.

CHANGING BANKS

The payee’s direct deposit will continue to be received by the bank until cancelled in writing using this form as provided above, or until the Department of Health and Human Services and the bank are notified by the payee (in writing using this form) that the payee wishes to change the bank that is receiving direct deposit. In addition, the payee must complete a new copy of this form with the newly selected bank.

FALSE STATEMENTS OR FRAUDULENT CLAIMS

State law provides a fine of not more than $2,000 or imprisonment for not more than one (1) year or both for giving false information in connection with making a written or electronic false statement that the party does not believe to be true (NH RSA 651:2 and 641:3).