ACH Authorization - Urgent Care Association

Authorization for Direct Deposit via ACH

Direct Deposit via Automated Clearing House (ACH) is the deposit of funds to a consumer's account for payroll, employee expenses reimbursement, government benefits, tax and other refunds, and annuities and interest payments.

Urgent Care Association is referred to as UCA in this form.

What event/activity/project are you submitting authorization for direct deposit of funds?

Please list the name of the event or activity or project.

Name *

First

Last

Email *

Bank Name

Account Number *

Account Type *

Checking
Savings

Bank Routing Number *

Check all to agree to the terms of this Direct Deposit authorization. *

I authorize UCA to electronically credit my account (and if necessary, debit my account to correct erroneous credits).*
I understand this authorization will remain in full force and effect until I notify UCA in writing (via email) that I wish to revoke this authorization.
I understand that UCA requires 7 days notice in order to cancel this authorization.**
I agree that ACH transactions I authorize will comply with all applicable laws.

* The National Automated Clearing House Association (NACHA) Operating Rules do not require the consumers express authorization to initiate reversing entries to correct erroneous transactions. however, Originators should consider obtaining express authorization of debits or credits to correct errors.

** Written credit authorization must provide that the receiver may revoke authorization only by notifying the Originator in the time and manner stated in the authorization. The reference to notification should be filled with a statement of the time and manner that notification must be given in order to provide the company a reasonable opportunity to act on it.

Contact Us

Legal & Privacy

Join Us