Audience
Zip code - drawer
County - drawer

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Automatic deposit (EFT/ACH credits) authorization agreement
All fields are required and must include completed information to ensure your request is processed quickly and accurately.
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Financial institution information. You must contact your financial institution to arrange for the delivery of the CORE-required Minimum CCD+ data elements needed for reassociation of the payment and the electronic remittance advice.

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that by using Regence Electronic Funds Transfer, we will no longer receive printed voucher summaries. I (we) certify that I am a duly authorized signer of the above designated bank account and as such hereby authorize Regence to initiate credit entries and, if and only to the degree necessary for any credit entries initiated in, debit entries to my (our) account indicated above and authorize the depository indicated above, hereinafter called DEPOSITORY, to credit and/or debit the same to such account. This authorization is to remain in full force and effective until Regence has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Asuris and DEPOSITORY a reasonable opportunity to act on it. In the event Asuris finds it necessary to initiate a correcting debit or credit entry, the account holder will be notified in advance. Modifications to this agreement will result in an automatic denial of your request to establish automatic deposit.

This field is mandatory.
This field is mandatory.

You must fax or email a copy of a voided check or bank letter to support this request. Please note that the name, address, account and routing numbers must be viewable. Bank deposit tickets, bank statements, and other items will not be accepted in lieu of a voided check or bank letter. Your EFT enrollment cannot be processed until one of these items is received.

This field is mandatory.
This field is mandatory.
This field is mandatory.