DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
PAYMENT INFORMATION REPORT
PERSONAL INFORMATION
Name
Address
City State ZIP Code
Home Phone
(
)
Work Phone
(
)
Social Security Number (or other Taxpayer Identification Number)
E-Mail
BANKING INFORMATION
(Complete this entire section or attach a voided check from your account.)
Name of Financial Institution
Address of Financial Institution
City State ZIP Code
Routing Transit Number (9 positions)
Account Title
Account Number
Type of Account (please check one)
Checking Savings
TRAVELER’S CERTIFICATION
Signature Date
PRIVACY ACT STATEMENT
The legal authority for the collection of information on this form is authorized by the Social Security Act (section 1155 of Title XI and
sections 1852(g)(5), 1860D-4(h)(1), 1869(h)(I), and 1876 of Title XVIII). The Social Security Number will be used to verify the identity
of the traveler. Submission of the information requested on this form is voluntary, but failure to provide all or any part of the requested
information may affect the ability to process your claim for reimbursement. The requested information concerns your financial institution,
your account at that institution, and personal information which needs to be provided to Department of Health and Human Services to
process your claim for reimbursement. This confidential information will be used by the U.S. Department of the Treasury to transmit
payment data by electronic means through the Automated Clearing House to your financial institution.
HHS-734 (09/05)
PSC Publishing Services (301) 443-6740
EF
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