Please mail completed form to PacificSource Administrators at the address above, or fax a copy
to (866) 446-6090. (Decorated checks and security watermarks can sometimes distort or hide
the account numbers when faxed.) Allow 10 working days for processing of this authorization.
You will receive regular reimbursement checks until this request is processed.
Important Information Regarding EFT/Direct Deposit Reimbursement
(Please read before signing Authorization Agreement form.)
• Participants who wish to have their reimbursement checks deposited directly into their bank
account must complete an Authorization Agreement for EFT/Direct Deposit Form and mail it
to PacificSource Administrators with their voided check.
• If you are currently enrolled in an FSA, HRA, and/or Transportation Plan, the information will
be entered and there will be a 10-day waiting period from the time PSA receives the
authorization until it takes effect.
• If you are a new enrollee in an FSA, HRA, and/or Transportation Plan, your EFT information
will be added after we receive and process your enrollment information. The 10-day waiting
period begins the day you are entered into our system. Physical checks will be issued during
that time. Claims will not be held for direct deposit.
• Once you agree to the EFT/Direct Deposit process, all reimbursement transactions will be in
this format until we receive your written request to cancel the process.
• No written notice of EFT/Direct Deposits will be sent.