Dental Electronic Funds Transfer (EFT) Authorization …
Category Code – PRIN GR-68960 (5-15) Page 3 of 4 Authorization Agreement – Please read and sign your name below. Electronic Funds Transfers (EFT) I hereby authorize Aetna, on behalf of itself and its affiliates, including Aetna Life Insurance Company, Aetna …
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Current Dental Terminology © American Dental …
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www.aetnadental.comElectronic Funds Transfer (EFT) Authorization Agreement ... account is the same for both Dental and Capitation claim payments. Capitation payments made under a single TIN can only be deposited into ... Dental Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) Authorization Agreement Please fax only one TIN per form. A ...
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