Direct Deposit Authorization Form
By Mail:
TELUS Health, 25 York Street, 20
th
floor,
Quad A, Toronto, Ontario, M5J 2V5
By Fax:
1 855 296-5515
OR OR
By E-mail:
provider.mgmt@telus.com
Organization / Individual Name Contact Person
Email Address
Address, City, Postal Code, Phone, Fax Registration Reference No.
(e.g., 20120913_0_004)
Date of Registration
Printed Name Signature Date
Part 1 – General Information
Part 2 – Banking Information
TELUS Health (“TELUS”) will process your on line registration upon receipt of this completed form accompanied by a copy of a pre-printed
void cheque with your name (Legal and/or Operating Name).
If you do not have a pre-printed cheque, please include a letter from your bank providing the account details and identifying you as the
account holder.
Part 3 – Authorized Signature
I hereby authorize TELUS to share banking information with the insurance companies (or payers), that are customers of the TELUS eClaims
solution and that participate in the electronic capture, validation and reimbursement of claims submitted from the providers’ point of service.
I also acknowledge and agree that TELUS may at times be acting on behalf of an insurance company for the payment of claims presented
through the TELUS claims adjudication services. I acknowledge that the insurance company makes the final decision on the admissibility of
any and all Claims and the amounts payable to the Providers for the services provided, and that TELUS has no responsibility of any nature
or kind in this regard.
Attach Void Cheque Here
A) I would you like to maintain one bank account to accommodate multiple services. (e.g., eClaims, WSIB): Yes No
Note: YES Please proceed to Part 3 No Please proceed to B
B) The bank account, as indicated by the void cheque attached above, is designated for:
Worker’s Compensation (WSIB) or Extended Healthcare (eClaims)
Note: Do not forget to attach another void cheque to this form with the service (WSIB or eClaims) clearly marked.
Day Month Year
Day Month Year
Print
Once this form is completed, you can return it along with your pre-printed cheque
AST2522-02-2019
