TX HHS Form 5022. HIPP Direct Deposit

The TX HHS Form 5022, "HIPP Direct Deposit", helps individuals manage their Health Insurance Premium Payment (HIPP) payments by allowing them to specify a bank account for direct deposit. This form is typically used in situations where an individual needs to update or establish a new payment method for their HIPP premium payments.

To complete this form, you will need to provide the required information about your bank account, including the name on the account, routing number, and account number. You must also provide your best phone number and email address for follow-up contact. Additionally, the person whose name appears on the check from HIPP must sign and date the form, indicating their agreement to have their HIPP checks deposited into the specified bank account.

To submit this form, you can fax it to 1-866-409-1188 (toll-free), email it to [email protected], or mail it to P.O. Box 201120 Austin, TX 78720-9774. You can also contact the HIPP Helpline at 1-800-440-0493 for assistance or visit the website at www.GetHIPPTexas.com for more information.

• This form is used to specify a bank account for direct deposit of Health Insurance Premium Payment (HIPP) payments.
• The required information includes name on the account, routing number, and account number.
• The person whose name appears on the check from HIPP must sign and date the form.