Electronic Deposit Authorization

If you would like to receive your Optuma payments via electronic deposit, please read, complete and sign this authorization form. Note that in some jurisdictions this is now the only method by which you can be paid by Optuma.


Company Name

Contact Name


Account Details

Routing Number

Account Number

Account Type



By signing this form, I authorize Optuma Pty Ltd to deposit funds directly into the account indicated below. I warrant that the details are correct, and I am responsible for any loss of funds associated with errors on this form.

Signed Date

October 16, 2019

Leave this empty:

Signature Certificate
Document name: Electronic Deposit Authorization
Unique Document ID: 42bfd071d8487f372962161ea713fbc75e13d95c
Timestamp Audit
June 6, 2019 11:17 am AESTElectronic Deposit Authorization Uploaded by Mathew Verdouw - forms@optuma.com IP