Account Number | Displays the account number for the EFT. |
City | Displays the city of the address for the payee provider. |
Contact Name | Displays the contact name for the payee provider associated with this EFT. |
E-Mail Address | Displays the contact's E-Mail Address for the payee provider. |
Fax Number | Displays the contact's fax number for the payee provider. |
Financial Institution Name | Displays the name of the financial institution associated with this EFT. |
Name of Signer | Displays the name of the person signing the EFT agreement. |
Payee Medicaid ID | Displays the Georgia Medicaid ID for the payee provider. |
Payee Provider Federal TIN or EIN | Displays the tax identification number (TIN) or federal employer identification (FEI) number of the payee provider. |
Payee Provider NPI | Displays the national provider identifier (NPI) of the payee provider. |
Payee Provider Name | Displays the name of the payee provider to whom EFT payment will be made. |
Requested EFT Start/Change/Cancel Date | Displays the date the EFT request was made. |
Routing Number | Displays the routing number of the financial institution to be associated with this EFT. |
Signing Date | Displays the date the EFT agreement is signed. |
State | Displays the state of the address for the payee provider. |
Street | Displays the street of the address for the payee provider. |
Telephone Number | Displays the contact's telephone number for the payee provider. |
Title of Signer | Displays the title of the person who will be signing the EFT agreement. |
Zip | Displays the zip of the address for the payee provider. |
Authorized Signature | This section of the panel contains information about the authorized signature for the EFT agreement. |
Financial Institution Information | This section of the panel contains information about the financial institution to be used in the EFT transaction. |
Include with Submission | This section of the panel displays the reason for submitting an EFT Agreement. |
Note | Displays important information about the fields in the Authorized Signature section and how to process the signature field on the form that is created. |
Pay To Provider Address | This section of the panel contains the address information about the payee provider. |
Payee Provider Contact Information | This section of the panel contains contact information for the payee provider. |
Payee Provider Identifiers | This section of the panel contains identifiers for the payee provider. |
Payee Provider Information | This section of the panel contains name and address information about the payee provider. |
Reason for Submission | This section of the panel displays the reason for submitting an EFT agreement. |
Select One Document | Displays the type of document that will be submitted with the EFT agreement. |
Select One Reason | Displays the selected reason for submitting an EFT Agreement. |
Type of Account | Displays the account type to be used in this EFT. |