Transcription of Electronic Funds Transfer (EFT) Authorization Agreement
{{id}} {{{paragraph}}}
Example: quiz answers
Electronic Funds Transfer (EFT) Authorization Agreement
PROVIDER INFORMATIONP rovider Name:Provider Address:Street:City:State/Province:Zip Code/Postal Code:PROVIDER IDENTIFIERS INFORMATIONP rovider Identifiers:Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN):National Provider Identifier (NPI): (Billing NPI must be 10 digits)PROVIDER CONTACT INFORMATIONP rovider Contact Name:Title:Telephone Number:Telephone Number Extension:Email Address: (Required, if applicable)Fax Number:FINANCIAL INSTITUTION INFORMATIONF inancial 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 Identifi
(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:
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document:
Related search queries
Consent to Receive Electronic Communications, Consent to do Business Electronically and to Use, Consent to do Business Electronically and to Use Electronic, Transactions, Electronic, Overview of electronic communications regulation, Electronic communications, Disclosure and Consent to the Use of Electronic, DISCLOSURE AND CONSENT TO THE USE OF ELECTRONIC COMMUNICATIONS Arvest, Electronic Transactions, ELECTRONIC COMMUNICATIONS ACT 36 OF, Electronic delivery, Scholarly Communication