Direct Deposit/ACH Authorization Form for VBIF Admitted Claimants & Family Members Only

The Virginia Birth-Related Neurological Injury Compensation Program has enlisted plan administrator, MC Innovations, and benefits manager, Rising Medical Solutions, to provide payment oversight and payment disbursements to Parties accepted into the Program (e.g., claimants, family members, authorized caregivers). In an effort to provide more timely and efficient disbursements to accepted Parties with regard to eligible benefit payments, please complete the secure direct deposit/ACH authorization form below. If payments for accepted Parties should go to different bank accounts, a separate Direct Deposit/ACH Authorization Agreement needs to be completed for each unique bank account.

PLEASE NOTE, the below form is intended for VBIF admitted claimants and family members only.  If you are a third party medical provider for a VBIF claimant, please enroll for EFT/ERA payments directly with ECHO Health, our payment processing partner. If you need further assistance, contact ECHO Health at allpayer@echohealthinc.com or 888.834.3511.

Direct Deposit/ACH Authorization Agreement for
VBIF Admitted Claimants & Family Members Only

I (we) hereby request and authorize Rising Medical Solutions, LLC and its affiliates (the “Company”) to deposit payments by electronic funds transfer into the Financial Institution account specified below and, if necessary, debit entries and adjustments for any amounts deposited electronically in error. I recognize that if this authorization agreement contains incomplete or inaccurate information, electronic payment processing may be delayed, or payments may be incorrectly transferred. This authorization agreement will remain in effect until the Company has received written notice to terminate ACH/Direct Deposit transactions to the specified account. By entering my electronic signature below, I (we) also acknowledge and agree to this Direct Deposit/ACH Authorization Agreement and the additional Terms and Conditions.

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Name of Financial Institution*

Address of Financial Institution*

Street Address/PO Box City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Routing Number (9 digits)*

*See below for example routing/account numbers

Account Number*

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Account Type*

Checking

Savings

Payee Name (must be same as name on bank account)*

Choose Verification Number to Include*

Federal Tax ID Number

Social Security Number (SSN)

Federal Tax ID*

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Social Security Number (SSN)*

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Authorized Signature / Check Signer*

Signator Printed Name*

Date*

MM slash DD slash YYYY

Email Address*

Telephone Number*

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