Skip to content
Are You in Need of Home Health Care Services?
Enroll Today
Home
About Us
About Us
Testimonials
FAQ’s
Blog
Home Care
Home Care
Medicaid Planning
Private Pay
Pediatrics
CDPAP
NHTD
NHTD
TBI
Work For Rockaway
Work With Rockaway
Employee Links
Keeper
Rockaway Rewards
Employee Referral Program
Forms
FSA Card(Melody)
Get Verified
Contact
Menu
Home
About Us
About Us
Testimonials
FAQ’s
Blog
Home Care
Home Care
Medicaid Planning
Private Pay
Pediatrics
CDPAP
NHTD
NHTD
TBI
Work For Rockaway
Work With Rockaway
Employee Links
Keeper
Rockaway Rewards
Employee Referral Program
Forms
FSA Card(Melody)
Get Verified
Contact
516-239-8693
Direct Deposit Authorization Agreement
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Direct Deposit Info
(Required)
Bank Name
Routing Number
Account Number
Amount/Percent
Checking or Savings
Add
Remove
Last 4 of Social Security #
(Required)
Consent
(Required)
I agree to the privacy policy.
I hereby authorize the Company to directly deposit any salary or wages due to me, less any mandatory or authorized withholdings or deductions in the bank account(s) listed above in the percentages specified. (If two or more accounts are designated, deposits are to be made in whole percentages of pay to total 100%.)
The Company will credit my account(s) the amount of my payroll check on payday. The Company will provide me with a check stub on payday listing my deductions and pay to be available on the Empeon Employee Self Portal. Deposits are normally available the morning of pay date however each bank posts funds to accounts at different times daily, and the Company has no control over my bank’s posting.
I authorize my financial institution to accept direct deposits to my account upon receipt and without advice to me. It is my responsibility to verify deposits on a per pay date basis before writing checks against these funds. I understand that the Company is not responsible for bank errors or bank fees. Banking services are provided in accordance with the limitations and restrictions of the Automated Clearing House Association.
This authorization is to remain in force until the Company has received written authorization from me of its termination or change. I understand that if my account has closed, my financial institution cannot accept a deposit on my behalf. If this occurs, my employer will not be able to process any further direct deposits without further written authorization from me. IN ORDER TO TERMINATE OR REVOKE THIS AUTHORIZATION, I MUST NOTIFY MY EMPLOYER IN WRITING AT LEAST TWO WEEKS PRIOR TO THE TERMINATION.
Changes to direct deposit may take 2-4 weeks to process.
Signed Name
(Required)
Signature Consent
(Required)
I agree that my signature on this document is as valid as if I signed the document in writing
Date Signed
(Required)
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
How can we help you?
Please select one option
Signup For Home Care
Signup For CDPAP
Signup For NHTD
Signup for Private Pay
Start Working With Rockaway
Name
First
Last
Email
Phone
Select Location(s)
(Required)
Brooklyn
Bronx
Manhattan
Queens
Staten Island
Rockland County
Suffolk County
Nassau County
Westchester County
Dutchess County
Orange County
Putnam County
Ulster County
Sullivan County
Are You?
(Required)
A licensed Home Health Aide (HHA)
A licensed Personal Care Aid (PCA)
CDPAP - I have a family member I want to care for
Looking for training
Are You The?
(Required)
Patient
Family
Friend
Other
Does the patient have Medicaid?
(Required)
Yes
No
I am not sure
What Is The Patients Medicaid Number?
Medicaid numbers should be in AB12345C format.
One MUST have MEDICAID to enroll in the CDPAP, NHTD And Homecare programs. Medicare is NOT enough
Would you like help applying or determining eligibility?
(Required)
Yes
No
Are you looking to pay privately or with long term care insurance?
(Required)
Yes
No
Again, one is NOT eligible to enroll in the CDPAP, NHTD or Homecare programs WITHOUT MEDICAID
Consent
Yes, Rockaway can contact me via txt, email, or calls to provide more information
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
How can we help you?
Please select one option
Signup For Home Care
Signup For CDPAP
Signup For NHTD
Signup for Private Pay
Start Working With Rockaway
Name
First
Last
Email
Phone
Select Location(s)
(Required)
Brooklyn
Bronx
Manhattan
Queens
Staten Island
Rockland County
Suffolk County
Nassau County
Westchester County
Dutchess County
Orange County
Putnam County
Ulster County
Sullivan County
Are You?
(Required)
A licensed Home Health Aide (HHA)
A licensed Personal Care Aid (PCA)
CDPAP - I have a family member I want to care for
Looking for training
Are You The?
(Required)
Patient
Family
Friend
Other
Does the patient have Medicaid?
(Required)
Yes
No
I am not sure
What Is The Patients Medicaid Number?
Medicaid numbers should be in AB12345C format.
One MUST have MEDICAID to enroll in the CDPAP, NHTD And Homecare programs. Medicare is NOT enough
Would you like help applying or determining eligibility?
(Required)
Yes
No
Are you looking to pay privately or with long term care insurance?
(Required)
Yes
No
Again, one is NOT eligible to enroll in the CDPAP, NHTD or Homecare programs WITHOUT MEDICAID
Consent
Yes, Rockaway can contact me via txt, email, or calls to provide more information
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.