Search results with tag "Eft authorization agreement"
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS …
www.cms.govELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT. PART I: REASON FOR SUbMISSION Ne. w EFT Authorization . Check here if EFT payment is being made to . ... information (using the Medicare enrollment application) to the Medicare contractor that services your geographical area(s) prior to or accompanying this EFT authorization agreement ...
Electronic Funds Transfer (EFT) & Electronic Remittance …
www.triwest.comAuthorization Agreement This form authorizes PGBA, LLC to administer any payment to you as an Electronic Funds Transfer (EFT). Please complete all fields on page 1 and 2 of this form. Form Completion Guidelines and Terms and Conditions can be found on pages 2 and 3. Please retain a copy of the completed EFT Authorization Agreement for your records.
TriWest Healthcare Alliance PGBA Claims Processor Frequently …
www.triwest.comEFT/ERA Enrollment Package and the PGBA EDI Provider Trading Agreement. Please allow time for processing before contacting PGBA for follow up. ... EFT Authorization Agreement PGBA, LLC PO Box 108853 Florence, SC 29502-8853 Or Fax: 803-419-3233 Phone: PGBA EFT Customer Service