Transcription of Electronic Funds Transfer (EFT) Authorization Agreement
{{id}} {{{paragraph}}}
Example: dental hygienist
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 financial institution to arrange for the delivery of the CORE-required Minimum CCD+ data elements needed for reassociation of the payment and the 835 INFORMATIONR eason for Submission: (Select one) c New Enrollment c Change Enrollment c Cancel EnrollmentInclude wi
activate electronic transfer of funds for all claims submitted by/on behalf of the enrolling provider, once claims are finalized. If you have questions regarding the EFT enrollment process, email : ecommerceservices @ bcbsil.com. To obtain the status of your enrollment, refer
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document:
Related search queries
Virginia Tax Electronic Payment Guide, Electronic, Electronic funds transfer, Transfer, Funds, Fidelity Funds, Fidelity, Electronic Funds Transfer Form, Electronic Funds Transfer Direct Deposit, New York State Comptroller, Electronic Funds Transfer (EFT) Authorization, For electronic, Money Laundering, Terrorist Financing and Transfer, Types of Electronic Banking