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EPS EFT Enrollment Authorization Agreement

EPS EFT Enrollment Authorization AgreementOptum is improving service to you by replacing paper checks and Explanation of Benefits (EOBs) with the Optum EPS solution. Get a head start by enrolling today! For more information about this Enrollment form, please see the Electronic payments & Statements EFT Enrollment Instructions by choosing the How to Enroll tab from the Optum EPS website type directly into this form or print clearly. Please complete all required information. All * fields are required. Provider Information *Provider Name: Provider Address*Street: ( Boxes are not accepted) *City: *State/Province: *Zip Code/Postal Code:Provider Identifiers Information Provider Identifiers*Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): National

Clearinghouse Association. These rules provide, among other things, that payments made to you, are provisional until final settlement is made through a Federal Reserve Bank or payment is otherwise made as provided in Article 4A-403(a) of the UCC. If we do not receive

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