Common Contracts
4 similar Form and Agreement contracts
Electronic Payment Authorization Form and AgreementForm and Agreement • November 22nd, 2020
This is an Agreement for electronic payments between Great Plains Medicare Advantage (“Payor”) and its applicable affiliate(s) and Name [ ],
Electronic Payment Authorization Form and AgreementForm and Agreement • November 22nd, 2020
This is an Agreement for electronic payments between LifeWorks Advantage Plan (“Payor”) and its applicable affiliate(s) and Name [ ],
This is an Agreement for electronic payments between Simpra Advantage (“Payor”) and itsForm and Agreement • November 22nd, 2020
SUBMISSION TYPE: NEWMUST SELECT ONE CHANGE CANCEL NPI NUMBER: TAX ID NUMBER: PAYEE NAME: REMIT TO ADDRESS: NAME OF PAYEE’S CONTACT: TELEPHONE: E-MAIL: PAYEE’S BANK or DEPOSITORY INSTITUTION ACCOUNT INFORMATION (US Based Banks ONLY) ACCOUNT TYPE CHECKING SAVINGS EFFECTIVE DATE OF CHANGE: BANK/DEPOSITORY INSTITUTION NAME: BANK/DEPOSITORY INSTITUTION ADDRESS: TELEPHONE:FAX:E-MAIL:BANK CONTACT NAME: BANK/DEPOSITORY ACCOUNT NAME: BANK/DEPOSITORY INSTITUTION ACCOUNT NUMBER: ABA/ROUTING NUMBER (9 DIGITS): E-MAIL ADDRESSES OF ANYONE WHO NEEDS TO BE NOTIFIED OF PAYMENTS: The undersigned Payee hereby authorizes Payor to initiate credit entries and to credit on or after the effective date specified to Payee’s above account at the above Bank (and to any additional Bank accounts of the Payee identified on addenda attached here to) that the Payee has correctly identified by ABA (American Banking Association) routing and account numbers. If Payee does not designate an effective date, the effe
This is an Agreement for electronic payments between ProCare Advantage (“Payor”) and itsForm and Agreement • November 22nd, 2020
SUBMISSION TYPE: NEWMUST SELECT ONE CHANGE CANCEL NPI NUMBER: TAX ID NUMBER: PAYEE NAME: REMIT TO ADDRESS: NAME OF PAYEE’S CONTACT: TELEPHONE: E-MAIL: PAYEE’S BANK or DEPOSITORY INSTITUTION ACCOUNT INFORMATION (US Based Banks ONLY) ACCOUNT TYPE CHECKING SAVINGS EFFECTIVE DATE OF CHANGE: BANK/DEPOSITORY INSTITUTION NAME: BANK/DEPOSITORY INSTITUTION ADDRESS: TELEPHONE:FAX:E-MAIL:BANK CONTACT NAME: BANK/DEPOSITORY ACCOUNT NAME: BANK/DEPOSITORY INSTITUTION ACCOUNT NUMBER: ABA/ROUTING NUMBER (9 DIGITS): E-MAIL ADDRESSES OF ANYONE WHO NEEDS TO BE NOTIFIED OF PAYMENTS: The undersigned Payee hereby authorizes Payor to initiate credit entries and to credit on or after the effective date specified to Payee’s above account at the above Bank (and to any additional Bank accounts of the Payee identified on addenda attached here to) that the Payee has correctly identified by ABA (American Banking Association) routing and account numbers. If Payee does not designate an effective date, the effe
