Direct Deposit Request Form

Part A: Payee Identification

Part B: Direct Deposit Information

  1. The intent of this request is to facilitate the payment of health benefit claims submitted by the Employee identified in Part A by Direct Deposit from Direct Reimbursement Associates Ltd. (DRAltd). DRAltd will credit the bank account of the Employee for the reimbursement amount of the health benefit claim submitted by the Employee.
  1. The initial and subsequent Direct Deposits will be made to the same bank account, identified below, until such time as the Employee notifies DRAltd of any change of the account. The Employee understands that providing new banking information replaces any banking information on file at DRAltd and will stay in effect until changed again by the Employee.
  1. The Employee may change or cancel these instructions at any time provided that DRAltd receives at least 5 business days’ notice by FAX or mail. The Employee may contact DRAltd at the contact information above.
  1. DRAltd uses a third party to administer Direct Deposits. This provider is currently Bambora of #200 – 1803 Douglas Street, Victoria, British Columbia, V8T 5C3.
  1. Privacy Notice: The personal information on this form and related attachments is collected by Direct Reimbursement Associates Ltd. for use only in depositing reimbursements or payments related to Private Health Services Plans (Health Spending Accounts). Your name, contact information, payment amount(s), bank account, will be disclosed to financial institutions and payment providers for Direct Deposit purposes only. Your personal information is protected and will only be used and disclosed in accordance with the Privacy Act. Individuals have the right to request access and correct their personal information, if erroneous or incomplete.
  1. The Employee acknowledges and agrees that the Employee is fully liable for any charges or delays incurred if the deposits cannot be made due to a closed or otherwise nonfunctional account for any reason. The Employee is accountable for compensation to DRAltd for any bank charges resulting.
  1. A VOID cheque or approved bank branch validation form must be attached with this agreement to verify the account information. DRAltd will retain the bank account information in their secure files so that it is only required once.
  1. By providing Direct Reimbursement Associates Ltd with a VOID cheque or bank branch validation form the employee accepts the foregoing conditions.

Part C: Bank Account Information