Appendix 10.1

Direct Deposit Authorization Form

Active clinic: [Company]

Use this form to authorize the [Company] to initiate direct deposits to your bank account. The authorization remains in effect until written notice of cancellation or change is provided.

Contractor, Employee, or Provider Information

Employee, representative, or contractor full name *

Organization full name (if applicable)

Organization Tax ID / EIN (if applicable)

Bank Account Information

Account holder name

Bank name

Routing number

Bank account number

Account type

Checking
Savings

Authorization

I hereby authorize the [Company] to initiate direct deposits to the bank account specified above. I understand that this authorization remains in effect until I provide written notice of cancellation or change of bank account information. I acknowledge that it is my responsibility to provide accurate bank account information and to promptly notify the payroll department of any changes. I release the [Company] from any liability that may arise due to errors or delays in the direct deposit process, provided the [Company] has acted in good faith and exercised reasonable care.

Date *

Employee Signature *

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