ATTACH VOIDED CHECK HERE OR. ON SEPARATE PAGE OR ATTACH A PHOTOCOPY OR BANK LETTER ON A SEPARATE PAGE SECTION FIVE – AUTHORIZATION By signing below, you confirm that the information that you have provided in this Agreement is true, complete and correct and you also hereby agree to the T&Cs set forth at xxxx://xxx.xxxxxxxx.xxx/im-online/terms_and_conditions.html, which is integral to, and forms a part of, this Agreement. Authorized Signature Name of Customer: Date: Signature: Print Name:
ATTACH VOIDED CHECK HERE OR. ON SEPARATE PAGE OR ATTACH A PHOTOCOPY OR BANK LETTER ON A SEPARATE PAGE SECTION FIVE – AUTHORIZATION The undersigned authorizes U.S. Bank and/or its healthcare network affiliate InstaMed Communications, LLC D.B.A InstaMed to make electronic payments and other entries to the bank account at the depository financial institution (depository) named above for services performed under the Agreement between the organization identified above and InstaMed and its affiliates. Such entries shall be made through the regional automated clearinghouse (ACH) associations, subject to any applicable Rules promulgated by such associations. This authorization is to remain in full force and effect until InstaMed has received written notice of its termination, allowing reasonable opportunity to act on it, which shall in no event be greater than thirty (30) days after its receipt. Revocation will not apply to transactions initiated before the effective date of such revocation. InstaMed may cease providing any or all of these services upon notice to Customer. The undersigned certifies that the above information is true and accurate in all respects and that the undersigned has the authority to initiate the actions requested herein and will promptly notify InstaMed of any changes to the information on this form in writing. As mandated by the Phase III CORE 370 EFT & ERA Reassociation (CCD+/835) Rule, Requirement 4.1, Customer must proactively contact its financial institutions in order to access the EFT trace number and other minimum data elements necessary to reassociate the EFT with the ERA. Authorized Signature Name of Customer: Date: Signature: Print Name:
ATTACH VOIDED CHECK HERE OR. ON SEPARATE PAGE OR ATTACH A PHOTOCOPY OR BANK LETTER ON A SEPARATE PAGE SECTION FIVE – AUTHORIZATION By signing below, you confirm that the information that you have provided in this Agreement is true, complete and correct and you also hereby agree to the T&Cs set forth at xxxx://xxx.xxxxxxxx.xxx/im-online/terms_and_conditions.html, which is integral to, and forms a part of, this Agreement. Authorized Signature Name of Customer: Date: Signature: Print Name: Print Title: xxx.xxxxxxxx.xxx 000 X. Xxxxxxxx, 0xx Xxxxx XXXXX XXXXX, XXXXXXXX 00000 (000) 000-0000 (000) 000-0000 FAX (000) 000-0000 INSTAMED ALL PLANS Changes to Existing Account To successfully resubmit your request please use the following steps: Login to: xxxxx://xxxxxx.xxxxxxxx.xxx/providers using your User ID, Password and Corporate ID. Select Trizetto Provider Solutions LLC under Remittance Delivery. If you have any additional questions, please contact InstaMed customer support at 000-000-0000. • Due to system or processing changes, it may be necessary for the payer to change their agreements. If this occurs during your enrollment process, you may be asked to complete an updated form. • If the Tax ID submitted on this enrollment form is associated with more than one office, all remittances for that Tax ID regardless of who submits the claim, will be returned to that vendor.
