The DHHS 2637 form is an authorization agreement for direct deposit, also known as electronic funds transfer (EFT), provided by the New Hampshire Department of Health and Human Services. This form allows enrolled providers to receive payments directly into their bank accounts, streamlining the payment process and eliminating the risks associated with lost or stolen checks. To ensure your payments are deposited efficiently, fill out the form accurately and submit it as instructed.
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The DHHS 2637 form is an important document for enrolled providers seeking to set up Direct Deposit or Electronic Funds Transfer (EFT) with the New Hampshire Department of Health and Human Services (DHHS). This form allows providers to authorize the DHHS to deposit payments directly into their bank accounts, streamlining the payment process. To complete the form, providers must fill out sections detailing their personal and banking information, including their name, address, and either their Employer Identification Number (EIN) or Social Security Number (SSN). A voided check or savings deposit slip is required to accompany the form, ensuring that the correct account is credited. Once submitted, it can take up to 30 days for the Direct Deposit to be activated, during which time providers will continue to receive paper checks. It is crucial for providers to verify that payments have been deposited into their accounts, as the DHHS does not guarantee deposits and is not responsible for any bank fees incurred. Should any changes occur in banking details or if providers wish to terminate the Direct Deposit, they must notify the DHHS and complete the necessary steps outlined in the form. Understanding these elements is essential for a smooth transition to Direct Deposit, which offers convenience and reduces the risk of lost or stolen checks.
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
TYPE OF TRANSACTION
NEW
TERMINATE
PROVIDER NAME (Last, First, Middle Initial)
DOING BUSINESS AS (DBA) (If you have a business name)
ADDRESS (Street, PO Box)
Select EIN or SSN only (according to how you are currently enrolled)
EMPLOYER IDENTIFICATION NUMBER (EIN)
-
OR
SOCIAL SECURITY NUMBER (SSN)
CITY
STATE
ZIP CODE
BRIDGES RESOURCE ID NUMBERS
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.
SIGNATURE
DATE
SECTION 2
NAME AND ADDRESS OF BANK
ROUTING NUMBER
ACCOUNT HOLDER NAME
DEPOSITOR ACCOUNT NUMBER
TYPE OF DEPOSITOR ACCOUNT
Checking
Savings
SECTION 3 (STATE OFFICE USE ONLY)
STATE AUTHORIZED REPRESENTATIVE’S NAME
SIGNATURE OF STATE AUTHORIZED REPRESENTATIVE
DATE RECEIVED
(Print)
PD 11-16
FORM 2637
JUNE 2011
DIRECT
DEPOSIT
EASIER ACCESS TO YOUR PAYMENTS
NO MORE LOST OR STOLEN CHECKS
NO MORE LONG BANK LINES
You can get a copy of this form from the website: http://www.dhhs.nh.gov/dcyf/cdb/forms.htm
WHAT IS DIRECT DEPOSIT?
Direct Deposit is also known as electronic funds transfer (EFT). You can authorize the New Hampshire Department of Health and Human Services (DHHS) to deposit your payments directly into your checking or savings account.
HOW DOES IT WORK?
DHHS electronically “tells” your bank to credit your account. In most instances, the payment will be received at your bank within two business days after DHHS disburses the payment. For each payment, be sure to verify with your bank that a deposit has been made prior to accessing funds. DHHS is not responsible for any fees you incur from your bank.
HOW DO I SIGN UP FOR DIRECT DEPOSIT?
Complete the authorization form according to the directions and mail the original form attaching a voided check or savings deposit slip to:
HOW LONG DOES IT TAKE?
It can take up to 30 days to process the request. You will continue to receive checks in the mail until Direct Deposit is authorized.
WHAT IF I HAVE MORE THAN ONE RESOURCE ID#?
Indicate all Resource ID Numbers for which you want Direct Deposit on this form.
HOW DO I KNOW WHEN DIRECT DEPOSIT BEGINS?
You will no longer receive a paper check. Be sure to check your account for a deposit from DHHS. A Remittance Advice statement does not guarantee that a deposit has been made into your account.
WHAT DO I NEED TO DO IF I CHANGE MY EXISTING ACCOUNT CONNECTED TO DIRECT DEPOSIT OR CHANGE BANKS?
If you change accounts at your bank or change banks, you must stop Direct Deposit as explained below and re-enroll for Direct Deposit.
HOW DO I STOP DIRECT DEPOSIT? ***IMPORTANT***
You must notify DCYF – Provider Relations at (603) 271-4954 prior to notifying your bank of any changes in your account. You must complete this form and check “Terminate” in the space “Type of Transaction”.
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).
Keep a copy of this form for your records
What is the DHHS 2637 form?
The DHHS 2637 form is an authorization agreement for Direct Deposit or Electronic Funds Transfer (EFT) specifically for enrolled providers under the New Hampshire Department of Health and Human Services, Division for Children, Youth and Families (DCYF). This form allows providers to receive payments directly into their bank accounts.
How do I fill out the DHHS 2637 form?
To complete the form, read the instructions carefully. Fill in your name, address, and either your Employer Identification Number (EIN) or Social Security Number (SSN). You must also provide your bank's name, routing number, and account number. Don’t forget to attach a voided check or savings deposit slip. Finally, sign and date the form before mailing it to the specified address.
How long does it take to process the DHHS 2637 form?
Processing your request can take up to 30 days. During this time, you will continue to receive paper checks until your Direct Deposit is fully authorized and activated.
What if I want to change my bank account?
If you change your bank account or switch banks, you must first stop your current Direct Deposit. To do this, notify DCYF – Provider Relations at (603) 271-4954. Then, complete the DHHS 2637 form again, checking “Terminate” in the Type of Transaction section, and provide the new bank information to re-enroll.
How will I know when my Direct Deposit has started?
Once your Direct Deposit is active, you will no longer receive paper checks. Instead, check your bank account for deposits from DHHS. Remember, a Remittance Advice does not guarantee that funds have been deposited.
What should I do if I need to stop Direct Deposit?
To stop Direct Deposit, you must notify DCYF – Provider Relations before informing your bank. Complete the DHHS 2637 form, marking “Terminate” in the Type of Transaction section. This will ensure that your payments are processed correctly and without delay.
Are there any fees associated with Direct Deposit?
While Direct Deposit itself does not incur fees from DHHS, any fees related to your bank account are your responsibility. DHHS is not liable for any charges your bank may impose.
What happens if I provide false information on the DHHS 2637 form?
Providing false information can lead to serious consequences, including fines of up to $2,000 or imprisonment for up to one year. It is crucial to ensure that all information submitted is accurate and truthful.
Understanding the DHHS 2637 form can be tricky. Here are ten common misconceptions that people often have about this important document:
Clearing up these misconceptions can help ensure a smoother experience with the DHHS 2637 form and direct deposit process.
The DHHS 2637 form, which is used for Direct Deposit or Electronic Funds Transfer (EFT) authorization, shares similarities with several other financial and authorization documents. Below is a list of these documents, each with a brief explanation of how they relate to the DHHS 2637 form.
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