ACH Form (Direct Deposit)

ACH Vendor Payment Setup Form

Note: CHECKING ACCOUNT ONLY
Thank you for your affiliation with Adventist HealthCare.

Please note that a voiced check is required when establishing or updating ACH payment instructions.

This voided check is uploaded, and the form cannot be completed without it. To prevent having to restart the form, please have this prepared prior to beginning.

Select One:*

NewUpdate
Company Name (Remit to Name):*
Remit to/Payment Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Tax ID Number:*
Contact Name:*
Contact Number:*
Please enter a valid phone number.
Contact Email Address(es):*
Remittance Email Address*
*Only 1 address can be used
By completing and signing this form, you authorize Adventist HealthCare to make payments directly to the bank account listed below. New accounts may take up to
1 week to complete. In the event an erroneous payment is identified by Adventist HealthCare, you agree that the funds will be returned within 5 business days upon
your agreement of the erroneous payment.

In the event you should need to update your bank information, ACH payments may cease and revert back to check payments until the new account information can be validated. In order to avoid any payment delays, all change requests must be received at least 5 business days prior to any upcoming invoice due date. This
request can be on either Adventist HealthCare's ACH Payment. Setup Form or a notarized memo on company letterhead accompanied by a bank letter providing the new account information.
Financial Institution:*
Bank Account Name:*
Bank Routing # (9 digits):*
Bank Account Number:*
Authorized signatory to sign below
Employee Signature:*

Clear
Employee Name:*
Employee Title:*
Date*

MonthDayYear
Date
Employee Email Address:*
example@example.com
Employee Phone Number: *
Please enter a valid phone number.
Voided Check upload*

Cancelof
Should be Empty:

ACH Vendor Payment Setup Form

Authorized signatory to sign below