Transcription of EFT Contact Request Form - Emdeon
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EFT Contact Request Form - Emdeon
EFT Contact Request /UPDATE To add a new Contact to your existing epayment enrollment please provide: Complete the Provider Information section Provide Identifiers Information If you choose to assign a delegate, enter Contact information under the Delegated (New) Contact section Electronic copy of a government issued ID from all delegates (with signature), on payee legal entities letter head. This is to include the original authorized signature holder. To replace the existing EFT Contact : Complete the Provider Information section Provider Identifiers Information If you choose not to assign a delegate, leave the Delegated Contact section blank Electronic copy of a government issued ID (with signature), on payee legal entities letter head Authorized Signature section EFT Contact Request Provider NameDoing Buisness As Name (DBA)Provider AddressStreetCityState/ProvinceZip Code/Postal CodeProvider InformationProvider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)
EFT CONTACT REQUEST /UPDATE To add a new contact to your existing Epayment enrollment please provide: • Complete the Provider Information section
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