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Authorization for Direct Debit Form

  1. Authorization For Direct Debit (pdf)

  2. Authorization For Direct Debit (Spanish) (pdf)

Illinois Department of Healthcare and Family Services offers the Authorization for Direct Debit Form for download in Portable Document Format (PDF).

In order to view or print these files in the PDF format, you will need Adobe's Acrobat Reader. You will need to download and install the Acrobat Reader, which is available from Adobe's Web site, on your computer. Click on the Adobe Icon for the free Download.

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Illinois Healthcare and Family Services

JB Pritzker, Governor • Theresa Eagleson, Director