FINANCIAL INSTITUTION INFORMATION. Financial Institution Name: Enter your Financial Institution’s name (this is the name of the bank or qualifying depository • that will receive the funds).
FINANCIAL INSTITUTION INFORMATION. Please provide a copy of a voided check or letter from your financial institution with your account number and routing number.
FINANCIAL INSTITUTION INFORMATION. Financial Institution Name* Official name of the provider’s financial institution. Financial Institution Routing Number* A 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited. Enter the number twice for validation. Provider’s Account Number With Financial Institution* Provider’s account number at the financial institution to which EFT payments are to be deposited. Enter the number twice for validation. Type of Account at Financial Institution* Check the type of account funds are to be deposited to. Enter the number twice for validation. Account Number Linkage to Provider Identifier (Select one and Fill in the Number) Provider preference for grouping (bulking) claim payments – much match preference for v5010X12835 remittance advice. NOTE: EFT data will always be linked by the MO HealthNet trading partner ID related to the NPI/taxonomy.
FINANCIAL INSTITUTION INFORMATION. Line 8: Enter your Financial Institution’s name (this is the name of the bank or qualifying depository that will receive the funds). Note: The account name to which EFT payments will be paid is to the name submitted on Part II of this form. Line 9: Enter the street address where your financial institution is located. Line 10: Enter the city, state, and zip code where your financial institution is located. Line 11: Enter the telephone number of your financial institution. Line 12: Enter the name of your account representative or contact person. Line 13: Enter the routing number for your financial institution. Line 14: Enter the account type. Line 15: Enter the deposit account number.
FINANCIAL INSTITUTION INFORMATION. Name of Financial Institution
FINANCIAL INSTITUTION INFORMATION. Enter the name, address, and telephone number of your Bank or Financial Institution.
FINANCIAL INSTITUTION INFORMATION. Financial Institution Centex Citizens Credit Union P.O. Box 1252 Mexia, Texas 76667 Routing Number 000000000 Financial Institution Phone Number 000-000-0000 Mexia 000-000-0000 Xxxxx 000-000-0000 Corsicana
FINANCIAL INSTITUTION INFORMATION. Financial Institution Name - Enter the designated Financial Institution name. Financial Institution Routing Number - Enter the Bank routing transit number. Type of Account at Financial Institution: - Indicate whether the account your EFT payments will be deposited to is a checking or savings account. Check only one box. Provider Account Number with Financial Institution - Enter the bank account number (not to exceed 17 digits). Account Number Linkage to Provider Identifier: Must fill out one of the two options below. Providers Tax Identification Number (TIN) – A federal tax identification number (TIN) or Employer identification number (EIN) Numeric, 9 digits. National Provider Identifier (NPI) – Unique identification number for covered healthcare providers. Numeric, 10 digits
FINANCIAL INSTITUTION INFORMATION. Financial Institution Name ABA Routing Number
