INSTRUCTIONS FOR COMPLETING THE …

INSTRUCTIONS FOR COMPLETING THE electronic FUNDS transfer authorization form To successfully authorize the use of electronic Funds transfer (or ACH) for the depositing of funds resulting from claims processed, all providers, group practices and facilities must follow all steps listed below. 1. Complete Sections A, B and C of the EFT Enrollment form . 2. All sections of this form must be completed in blue or black ink and in a complete and legible manner or the request will not be processed and will be returned. 3. Mail the completed form to: Insurance Service Center (EFT Enrollment) Box 13667 Pensacola, FL 32591 4. Only one Tax ID number and one associated NPI is allowed per application form 5. Only one bank account number is allowed per application form .

INSTRUCTIONS FOR COMPLETING THE ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM To successfully authorize the use of Electronic Funds Transfer (or ACH) for the depositing of funds resulting

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