Common Contracts
1 similar Election Agreement contracts
Provider Election AgreementElection Agreement • November 18th, 2015
The fully executed Provider Election Agreement, along with a copy of your W-9, should be returned via facsimile to: Aflac Group Attn: Aflac Group EFTFacsimile: 866.849.2970 Please complete ALL fields, and print clearly. This Provider Election Agreement should be used by Providers electing to utilize the “Banking Service,” an enrollment and claims payments tool offered by J.P. Morgan Chase Bank, N.A. (the “Bank”), that automates the processing and reconcilement of payments, including the receipts and delivery of 835s and Explanation of Benefits (EOBs) from Aflac Group and to its Providers registered with the Bank. By submitting this completed Provider Election Agreement to Aflac Group, the Provider named herein is authorizing Aflac Group to share information with, and process payments through, the Bank and Healthcare Link Service, as more fully explained herein.Separate registration with the Bank is required to obtain and utilize the Banking Service. Banking information should not be su
