Transcription of Electronic Funds Transfer (EFT) Authorization Agreement
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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 Identification Number (TIN) c National Provider Identifier (NPI)Note: If enrolled for 835 Electronic Remittance Advice (ERA), the provider must contact their fi
(EFT Enrollment Authorization Agreement, Page 2) OTHER DATA In addition to the maximum data elements required for EFT enrollment, BCBSIL will need …
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