INSTRUCTIONS FOR COMPLETING THE ELECTRONIC FUNDS …

1 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.

2 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 . 6. For questions, please call our EFT Information line at 877-891-7796 or e-mail us at WHAT TO EXPECT Please allow a minimum of 4-6 weeks for your request to be processed. INSTRUCTIONS TO CHANGE BANKING INFORMATION To change banking information providers must send the following: 1. Complete a new EFT Enrollment form marking the Change Box at the top of the form . 2. Update all changed information in sections A and B and complete the signatures in section C. 3. Once the form is received all information will be updated, however, payments may revert to paper checks during the transition 2-4 weeks.

3 INSTRUCTIONS TO CANCEL EFT TRANSACTIONS To cancel EFT transactions, providers must send the following: 1. Complete a new EFT Enrollment form marking the Cancel Box at the top of the form . 2. Fill out all information in section A, leave section B blank and complete the signatures in section C. 3. Once the form is received, please allow 4-6 weeks for the cancellation to take effect and to start receiving paper checks again. EFT Enrollment form To request ELECTRONIC FUNDS transfer for claims processed by CHCS Service, you must complete all sections of this form . Please follow all steps as outlined in the EFT Enrollment form INSTRUCTIONS and return by one of the methods noted in the INSTRUCTIONS .

4 For any questions regarding this form , call 877-891-7796 Reason For Enrollment Submission: New Change Cancel Submission Date Requested Start/Change/Cancel Date Section A: Complete All Provider Information Fields Provider/Organization Name Pay To Address City State Zip Code Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) National Provider Identification (NPI) Provider Identifier Linkage if also enrolled in ERA TIN NPI Provider Contact Name Telephone Number Email Address Fax Number Section B: Complete All Banking Information Bank Name Address City State Zip Code Routing Number Account # Account Type (select one) Checking Savings Section C.

5 Signature (required) If submitting this form for an individual practitioner, the practitioner must sign below. If submitting this form for a group, business or institution, the authorized representative must sign below. Signature of Practitioner/Authorized Representative Date Signed Printed Name of Person Submitting Enrollment Title **This form will be returned if the information is incomplete or not legible. **Mail the completed form to: Insurance Service Center (EFT Enrollment) Box 13667 Pensacola, FL 32591