Contact Name E-mail
Title Phone ( ) -
Action: Initiate ACH Change ACH information
We hereby authorize LifeWise Health Plan of Oregon (LifeWise) or its designee to initiate debit and/or
credit entries to our bank account indicated below and, if applicable, to debit or credit the same to such
account related to the funding of and/or claims payments from the funding account(s) administered by
LifeWise on our behalf. We acknowledge that the origination of Automated Clearing House (ACH)
transactions to our account must comply with applicable law.
Bank Routing Number
(e.g., nine-digit ABA number)
Tip Your bank may have a separate routing number for
ACH transactions. Please verify the routing number
with your financial institution to prevent delays.
Bank Account Number
Type of Account (please check one) Checking Savings
Bank Account Name
(e.g., general checking account, operating account)
This authorization is to remain in full force and in effect until LifeWise has received written notification
from us of its termination in such time and in such manner as to afford LifeWise and our bank a
reasonable opportunity to act on it. We understand that changes to any information on this form must
be submitted by the close of business Monday to ensure that these changes will take effect by the
The undersigned is authorized to sign this funding authorization on behalf of the company.
Note LifeWise or its designee may run a test of the ACH process (i.e. pre note) to be sure it is working properly.
You may see a transaction on the account with a $0 charge.
Return completed and signed form to your LifeWise Sales Representative.
For LifeWise Use Only: Group ID Number ____________________ Subgroup(s) ______________________________
FACETS HRA — GSU (FAX 425-918-6080) CYC PFA — CYC NON-HRA — FINANCE