EFT Agreement

Tuesday, December 5, 2023

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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.

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»	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.

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Electronic Funds Transfer Agreement