EFT Agreement

Tuesday, July 15, 2025

Skip to Provider Enrollment Subsystem Menu

<- Bookmarkable Link Bookmark star and question mark Click here for help and information about bookmarks

(click to hide) Alert Message posted 7/15/2025

System Maintenance Starting at 7pm Eastern on Friday, July 18, 2025

On Friday, July 18, 2025, starting at 7pm Eastern time, the web portal will be closed for maintenance.

During this maintenance all pages of the web portal will be unavailable and a maintenance notice will be displayed. Once the maintenance is complete, the notice will be removed and normal access will resume.

»	User Information



Login/Manage Account Login/Manage Account	Login

File Download Issues

Some users may have difficulty downloading files. Often this is caused by pop-up windows being blocked or by security settings in the browser. Click here for help with download issues.

Note: By pressing the create button, the next page that appears is an application for Electronic Funds Transfer. The application form that appears will be pre-filled with the information provided on this page, but it must still be signed to signify agreement with the terms on page 2 of the form. Both pages must then be sent in along with any additionally required documentation.

create

clear

»	Electronic Funds Transfer Agreement

Payee Provider Information Payee Provider Information
Payee Provider Name* Payee Provider Name*	Payee Provider Name: Required input must be between 1 And 50.
Pay To Provider Address Pay To Provider Address
Street* Street*	Street: Required input must be between 1 And 60.	State* State*
City* City*	City: Required input must be between 1 And 30.	Zip* Zip*	Zip: Enter a valid value Zip + 4 Zip + 4 Enter a valid value
Payee Provider Identifiers Payee Provider Identifiers
Payee Medicaid ID Payee Medicaid ID	Payee Medicaid ID: Required input must be 10 characters in length.	Payee Provider NPI Payee Provider NPI	Payee Provider NPI: Required input must be 10 characters in length. Payee Provider NPI: Only numeric Values are allowed.
Payee Provider Federal TIN or EIN* Payee Provider Federal TIN or EIN*	Payee Provider Federal TIN or EIN: Required input must be 9 characters in length. Payee Provider Federal TIN or EIN: Only numeric Values are allowed.
Payee Provider Contact Information Payee Provider Contact Information
Name* Name*	Name: Required input must be between 1 And 50.	Telephone Number* Telephone Number*	Telephone Number: Enter a valid value
E-Mail Address E-Mail Address	E-Mail Address: Enter a valid value	Fax Number Fax Number	Fax Number: Enter a valid value
Financial Institution Information Financial Institution Information
Name* Name*	Name: Maximum characters required is (50).	Type of Account* Type of Account*	Checking Saving
Routing Number* Routing Number*	Routing Number: Required input must be between 9 And 10. Routing Number: Only numeric Values are allowed.	Account Number* Account Number*	Account Number: Required input must be between 1 And 17.
Reason for Submission Reason for Submission		Include with Submission Include with Submission
Select One Reason* Select One Reason*	Cancel Enrollment Change Enrollment New Enrollment	Select One Document* Select One Document*	Bank Letter Cancelled Check
Authorized Signature Authorized Signature
Note Note	This information will appear on the form that gets created; however, the signature field will be empty within the form and must therefore be signed before sending in the EFT Agreement.
Name of Signer* Name of Signer*	Name of Signer: Required input must be between 1 And 50.	Signing Date* Signing Date*	Signing Date: Invalid date. Format is mm/dd/ccyy. Signing Date: must be greater than or equal to 1/1/1900. Signing Date: must be less than or equal to 12/31/2299.
Title of Signer* Title of Signer*	Title of Signer: Required input must be between 1 And 50.	Requested EFT Start/Change/Cancel Date* Requested EFT Start/Change/Cancel Date*	Requested EFT Start/Change/Cancel Date: Invalid date. Format is mm/dd/ccyy. Requested EFT Start/Change/Cancel Date: must be greater than or equal to 1/1/1900. Requested EFT Start/Change/Cancel Date: must be less than or equal to 12/31/2299.

top of page

	English \| Español \| Accessibility \| Privacy \| AMA & ADA Copyright
© Copyright 2025 Gainwell Technologies

User Information

Electronic Funds Transfer Agreement