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Direct Deposit Form for Already Established DDB Reimbursement Requests


  1. Information
  2. Direct deposit verification
  3. Signature/Authorization

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Information

Please complete all required fields below to ensure your form is processed promptly. Fields marked with * are required.





Direct deposit verification

You are electing to have your reimbursement made by direct deposit to a designated bank account. Fields marked with * are required.

Account Information

Account type*:






Financial Institution Information




Upload Check

Please upload an image of the voided check.

Signature/Authorization

Please acknowledge the following information before signing. *These fields are required.








Thank you for your submission

Your Direct Deposit Form for Already Established DDB Reimbursement Requests has been submitted. If you also submitted for reimbursement, please allow approximately 14 business days to see your funds deposited to your account.

If you have questions about your request, please contact UPMC Benefit Management Services at 1-888-499-6885.