Common Contracts
1 similar Electronic Funds Transfer (Eft) Authorization Agreement contracts
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • November 29th, 2016
Provider Name Tax ID □ EIN □ SSN Street City State Zip Provider Contact Phone Fax ** Email ** 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: Financial Institution Phone Account Name ** ABA/Routing No. Account Type: □ Checking □ Saving ** Account No. ** Please include a confirmation of account information on bank letterhead or a voided check for account verification. Ifsubmitting bank letterhead, the bank officer’s name and signature is required.
