Transcription of EPS EFT Enrollment Authorization Agreement - Optum
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EPS EFT Enrollment Authorization Agreement - Optum
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 Provider Identifier (NPI):*Provider Type: Hospital/Facility Physician (Group/Individual Practice) Other Healthcare services organization (DME, Home Health Services, Laboratory Services, other)*Provider Type: Behavioral Health Dental Medical Vision OtherProvider Contact Information *Provider Co
Optum is improving service to you by replacing paper checks and Explanation of Benefits (EOBs) with the Optum EPS solution. ... If you have additional NPI/Bank account information that you would like to enroll, ... Otherwise make copies of this blank form for paper enrollment. Submission Information Reason for Submission: New Enrollment Change ...
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