INSTRUCTIONS: ALABAMA DIRECT DEPOSIT AUTHORIZATION AGREEMENT (Form ACT-18)

Alabama public employees enrolled in health insurance through BlueCross BlueShield use a form ACT-18 to authorize direct deposits of credits from their insurance into their bank accounts. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 1: Indicate whether this concerns a health, dental or preferred blue account with a check mark.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 2: Indicate whether you wish to add, cancel or change account information with a check mark.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 3: Enter the subscriber name on the first blank line.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 4: Enter the contract number on the second blank line.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 5: Enter the subscriber's daytime phone number on the third blank line.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 6: Check the box next to the first statement if authorizing credits to be entered to your checking account.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 7: Check the box next to the second statement if authorizing credits to be entered to your savings accounts.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 8: On the next blank line, enter the name on the account.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 9: On the next blank line, enter the bank name.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 10: On the next blank line, enter your ABA routing number.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 11: On the next blank line, enter your account number.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 12: On the next blank line, enter your signature.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 13: On the last blank line, enter the date.

Alabama Direct Deposit Authorization Agreement ACT-18 Step 14: Along with your application, you must submit a canceled or voided check. The form may be submitted electronically at the website given at the top of the form. You may also fax the form, along with the voided address, to the number given at the bottom of the page. You may also choose to mail the form and the voided check to the address given at the bottom of the page.