Common Contracts
3 similar Electronic Funds Transfer (Eft) Authorization Agreement contracts
Claim Payment EXNV Electronic Funds Transfer (EFT) Authorization Agreement ⃝ New ⃝ Change ⃝ CancelElectronic Funds Transfer (Eft) Authorization Agreement • October 25th, 2023
** The EOB for payment will be sent ONLY via email once you enroll to receive claim payment via EFT. If EOB should be sent to a different email, please list a different email here:
Claim Payment EXTX Electronic Funds Transfer (EFT) Authorization Agreement ⃝ New ⃝ Change ⃝ CancelElectronic Funds Transfer (Eft) Authorization Agreement • October 17th, 2022
** The EOB for payment will be sent ONLY via email once you enroll to receive claim payment via EFT. If EOB should be sent to a different email, please list a different email here:
Claim Payment EXAZ Electronic Funds Transfer (EFT) Authorization Agreement ⃝ New ⃝ Change ⃝ CancelElectronic Funds Transfer (Eft) Authorization Agreement • October 17th, 2022
** The EOB for payment will be sent ONLY via email once you enroll to receive claim payment via EFT. If EOB should be sent to a different email, please list a different email here:
