RFR Attachment 12 - Electronic Payment via ACH~1.pdf
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- Solicitation number
- BD-25-1175-1175C-1175L-127564
- Issued by
- Massachusetts
About this file
This is an Electronic Payment Authorization Form issued by the Commonwealth Health Insurance Connector Authority (CCA), a Massachusetts state agency. The form establishes procedures for vendors and contractors to receive payments from CCA via Automatic Clearing House (ACH) direct deposit rather than traditional check payments. Contractors must complete all required fields on the form, including payee information, financial institution details, bank account number, routing number, and account type designation. The form requires submission of supporting documentation, either an original voided check or bank verification letter, to facilitate account validation. Completed forms must be submitted to stacy.halloran@mass.gov. The authorization provides three action options: new enrollment for initial ACH setup, change of information for updating existing ACH details, or terminate/cancel to discontinue electronic payments.
The payee authorization remains in effect until CCA receives written termination notice and has reasonable opportunity to process it. By signing the form, authorized representatives certify that they have authority to direct ACH deposits and acknowledge CCA's right to initiate debit entries or adjustments for erroneous credit entries to the designated bank account. The form emphasizes that contractors must notify CCA if their account is closed to prevent payment delays, and that all future payments will be processed via ACH unless formal termination is requested. This document serves as a standard financial administration requirement for state contractors receiving Commonwealth payments.
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Text version
RFR ATTACHMENT 12 – ELECTRONIC PAYMENT AUTHORIZATION FORM
The Commonwealth of Massachusetts
Commonwealth Health Insurance Connector Authority 100 City Hall Plaza Boston, MA 02108
MAURA T. HEALEY
Governor
KIMBERLY DRISCOLL
Lieutenant Governor
Electronic Payment Authorization Form via ACH
KATHLEEN E. WALSH
Board Chair
AUDREY MORSE GASTEIER
Executive Director
Complete all information on this form.
Attach an original voided check or bank verification letter to this form (failure to provide documents may delay processing).
Please send the form to stacy.halloran@mass.gov
Payee/Financial Information
Payee Name:
Mailing Street Address:
Mailing City, State and Zip:
Contact Name:
Contact Phone #:
ACH Notification Email Address:
Name of Financial Institution:
Bank Account Number:
Bank Account Routing Number:
Type of Account (Check One): ☐ Checking ☐ Savings
Action (Check One): ☐ New Enrollment ☐ Change of Information ☐ Terminate/Cancel Authorization
Attachment (Check One): ☐ Voided Check ☐ Bank Verification Letter
Payee Certification
I hereby authorize, as an authorized signer of the above referenced payee, the Commonwealth Health Insurance Connector Authority (CCA) to direct deposit via Automatic Clearing House (ACH) all entitled payments and to initiate (if necessary) debit entries or adjustments for any credit entries made in error to the above referenced bank account.
This authorization will remain in effect until CCA has acted on a written request for termination. Such termination must be made in such time and in such manner as to afford the CCA a reasonable opportunity to act on it. All future payments from CCA will be made via ACH until such termination. I understand that if my account is closed without providing the CCA written notice, my payment may be delayed.
Authorized Representative (print): Title:
Payee (or Authorized Representative) Signature: Date:
mailto:stacy.halloran@mass.gov
File details come from the government source that posted it. Updated .