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EFT Agreement Panel
The EFT (Electronic Funds Transfer) Agreement panel allows users to create a PDF request for EFT changes or additions. The user may print or save the document, after which, they must follow the instructions and return the completed form and required attachment(s) to the address indicated.

Navigation Path: [Provider Enrollement] - [EFT Agreement]
Field Descriptions:
FieldDescription
Account NumberDisplays the account number for the EFT.
CityDisplays the city of the address for the payee provider.
Contact NameDisplays the contact name for the payee provider associated with this EFT.
E-Mail AddressDisplays the contact's E-Mail Address for the payee provider.
Fax NumberDisplays the contact's fax number for the payee provider.
Financial Institution NameDisplays the name of the financial institution associated with this EFT.
Name of SignerDisplays the name of the person signing the EFT agreement.
Payee Medicaid IDDisplays the Georgia Medicaid ID for the payee provider.
Payee Provider Federal TIN or EINDisplays the tax identification number (TIN) or federal employer identification (FEI) number of the payee provider.
Payee Provider NPIDisplays the national provider identifier (NPI) of the payee provider.
Payee Provider NameDisplays the name of the payee provider to whom EFT payment will be made.
Requested EFT Start/Change/Cancel DateDisplays the date the EFT request was made.
Routing NumberDisplays the routing number of the financial institution to be associated with this EFT.
Signing DateDisplays the date the EFT agreement is signed.
StateDisplays the state of the address for the payee provider.
StreetDisplays the street of the address for the payee provider.
Telephone NumberDisplays the contact's telephone number for the payee provider.
Title of SignerDisplays the title of the person who will be signing the EFT agreement.
ZipDisplays the zip of the address for the payee provider.
Authorized SignatureThis section of the panel contains information about the authorized signature for the EFT agreement.
Financial Institution InformationThis section of the panel contains information about the financial institution to be used in the EFT transaction.
Include with SubmissionThis section of the panel displays the reason for submitting an EFT Agreement.
NoteDisplays 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 AddressThis section of the panel contains the address information about the payee provider.
Payee Provider Contact InformationThis section of the panel contains contact information for the payee provider.
Payee Provider IdentifiersThis section of the panel contains identifiers for the payee provider.
Payee Provider InformationThis section of the panel contains name and address information about the payee provider.
Reason for SubmissionThis section of the panel displays the reason for submitting an EFT agreement.
Select One DocumentDisplays the type of document that will be submitted with the EFT agreement.
Select One ReasonDisplays the selected reason for submitting an EFT Agreement.
Type of AccountDisplays the account type to be used in this EFT.
FieldError MessageTo Correct
Account Number Account Number is required.Enter an account number.
City City is required.Enter a city.
Contact Name Name is required.Enter a contact name.
Financial Institution Name Name is required.Enter a financial institution name.
Name of Signer Name of Signer is required.Enter the name of the signer.
Payee Medicaid ID Payee Medicaid ID is required.Enter a valid payee Medicaid ID.
Payee Medicaid ID is not a valid Payee Medicaid ID. The Payee Medicaid ID can be found on previously received Remittance Advices or it can be left blank if there is no existing Payee Medicaid ID.Enter a valid payee Medicaid ID.
Payee Provider Federal TIN or EIN Payee Provider Federal TIN or EIN is required.Enter a payee provider federal TIN or EIN.
Payee Provider Name Payee Provider Name is required.Enter a payee provider name.
Requested EFT Start/Change/Cancel Date Requested Date is required.Enter the requested date.
Routing Number Routing Number is required.Enter the routing number.
Signing Date Signing Date is required.Enter a signing date.
State A valid State is requiredSelect a state.
Street Street is required.Enter a street.
Telephone Number Telephone Number is required.Enter a telephone number.
Title of Signer Title of Signer is required.Enter the title of signer.
Zip Zip is required.Enter a zip.
Select One Document Select one document is required.Select one document to be attached to the agreement.
Select One Reason Select one reason is required.Select one reason for the completed agreement.
Type of Account Type of Account is required.Select a type of account.