Electronic Funds Transfer (EFT) Authorization Agreement
PROVIDER INFORMATIONProvider Name:Provider Address:Street:City:State/Province:Zip Code/Postal Code:PROVIDER IDENTIFIERS INFORMATIONProvider Identifiers:Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN):National Provider Identifier (NPI): (Billing NPI must be 10 digits)PROVIDER CONTACT INFORMATIONProvider Contact Name:Title:Telephone Number:Telephone Number Extension:Email Address: (Required, if applicable)Fax Number:FINANCIAL INSTITUTION INFORMATIONFinancial Institution Name:Financial Institution Address:Street:City:State/Province:Zip Code/Postal Code:Financial Institution Routing Number:Type of Account at Financial Institution:Provider s Account Number with Financial Institution:Account Number Linkage to Provider Identifier: (Select one) c Provider Tax Identificati
(EFT Enrollment Authorization Agreement, Page 2) OTHER DATA In addition to the maximum data elements required for EFT enrollment, BCBSIL will need the following information to finalize your request:
Download Electronic Funds Transfer (EFT) Authorization Agreement
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