Direct Deposit Enrollment for Broker Payments
Add direct deposit Change direct deposit Terminate direct deposit - I hereby request Kaiser Permanente to terminate direct deposit of
my Broker reversal of disbursements. No attachment is required to request termination of direct deposit
_________________________________________ ______________________________________ _________________________ ____________________________
Broker’s Name (Name as it appears on check ) Name of Business (DBA with Kaiser Permanente) Broker ID (B ID) OneLink Vendor Number (internal use)
_______________________________________________________ _____________________________________________ ______________________________________
Business Mailing Address: Street City, State, Zip Code Daytime Phone Number
_______________________________________________________ _____________________________________________ ______________________________________
Pay To Address: Street City, State, Zip Code E-mail contact for deposit notifications
(If multiple Pay To’s for TIN and vendor # please list on separate sheet)
___________________________________________
Authorized signatory (please print)
___________________________________________
Title
___________________________________________
Signature & Date
Completed forms can be faxed,
emailed or mailed to:
Fax: (855) KP PAYMENT (855-577-2963)
Email: BCS_CA_DocAdministration@kp.org
Mail: Kaiser Permanente
Attn: Broker Compensation Services
PO Box 23250
San Diego, CA 92193-9917
For Checking account: Please attach a voided check or attach on a
separate page
For Savings account: Please attach a deposit slip or attach on a
separate page
To be eligible for enrollment, you must be a Broker with Kaiser Foundation Health Plan, Inc. (Kaiser Permanente) and have a valid bank account (checking or savings).
Instructions:
1. You are authorizing Kaiser Permanente to deposit payments for commissions associated to the Tax ID and
the bank account listed above.
2. You must complete the information on this form and attach a copy of a voided check or savings deposit slip.
You can mail, fax or scan the completed information to Broker Compensation Services. Please submit request 5
days prior to any given commission run for processing.
3. You must verify that your financial institution can receive electronic funds transfer transactions, and obtain
the institution’s 9-digit bank routing number.
4. You are responsible for notifying the Kaiser Permanente Ecommerce Dept. of bank account and email
address changes. To change this information, you must submit a new direct deposit
request form. Please submit request 5 days prior to any given commission run for processing.
5. You will receive a remittance advice after the funds have been deposited into your account if you include an
email address on the form above. If you do not receive either the funds or your remittance advice, please call
Customer Service at (800) 390-3510.
The undersigned individual represents that he or she is
fully authorized to execute this form and to authorize the
transactions described herein on behalf of the identified
Provider entity. I hereby authorize Kaiser Permanente to
deposit payments and approve any such funds if deposit is
submitted in error into the financial institution and account
indicated below. See instructions below for necessary
attachments.
Checking account
Savings account
click to sign
signature
click to edit
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