Common Contracts
2 similar Form and Agreement contracts
This is an Agreement for Electronic Funds Transfer (EFT) between NHC Advantage Plan Missouri (“Payor”) and itsForm and Agreement • August 2nd, 2021
.MUST SELECT ONE ☐ NEW AGREEMENT ☐ CHANGE ACCOUNT ☐ 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 INSTITUTIONADDRESS: 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
This is an Agreement for Electronic Funds Transfer (EFT) between LifeWorks Advantage Plan (“Payor”) and itsForm and Agreement • August 2nd, 2021
.MUST SELECT ONE ☐ NEW AGREEMENT ☐ CHANGE ACCOUNT ☐ 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 INSTITUTIONADDRESS: 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.
