Direct Deposit Authorization Form for Electronic Funds Transfers (EFT) for Medicaid Providers Payee Information Name of Business or Individual Street Address Medicaid Provider Number City SSN or EIN State Zip Code Attach a voided check and sign the Authorization for Setup below. (A photocopy of a voided check will not be accepted). Do not attach a deposit slip since deposit slips do not contain sufficient information for processing. Provide financial institution name, city, state and zip code on this form, and sign the Authorization for Setup below. Financial Institution Financial Institution Name City State Zip Code Authorization For Setup I hereby authorize the State of Utah (“the State”) to initiate credit entries to the account number listed above (“this account”). I further authorize the State to correct credit entries made in error to this account. I agree that this AUTH ORIZA TIO N FO R SET UP is to remain in full force and effect until the State has received written notification from me of its termination, in such time and manner as to afford the State and the Financial Institution a reasonable o ppo rtunity to ac t upon my no tification. I recognize that if I fail to provide comp lete or accurate information on the above DIRECT DEPOSIT AUTH ORIZATION FORM FOR ELECTRONIC FUNDS TRANSFERS (EFT) FOR MED ICAID PROVIDERS (“this form”), the processing of this form may be delayed and/or my payments may be erroneously transferred. In the event that funds are erroneously transferred due to my failure to provide complete or accurate information on this form, I hereby ho ld the State harmless for the recovery of such erroneous transfers, not withstanding any reasonable attempts made by the State to corre ct such errors. I understand that payment will be from Federal and State funds and that any falsification or concea lment of a material fact, may be prosec uted unde r Federa l and State laws. I, the undersigned certify that I am authorized to provide the above information and the information is true and correct. Authorized Signature Return form to: Bureau of M edicaid Operations PO Box 143106 Salt Lake City, UT 84114-3106 Date Telephone Number 4/14/05 American LegalNet, Inc. www.FormsWorkFlow.com