Common Contracts

Electronic Funds Transfer (EFT) Authorization Agreement

December 20th, 2013

• Filed
  December 20th, 2013

By completing and submitting this form to the Missouri Medicaid Audit and Compliance Unit (MMAC) for processing, I understand• payment will be from Federal and State funds and that any falsification or concealment of material fact may be prosecuted under Federal and State laws;• the State of Missouri will initiate credit entries (deposits) and will initiate, if necessary, debit entries (withdrawals) or adjustments for any credit entries made in error to my account;• the State of Missouri may terminate my enrollment in direct deposit if the State is legally obligated to withhold part or all payments for any reason;• MMAC may terminate my enrollment if I no longer meet the eligibility requirements; and• this document does not constitute an amendment or assignment of any nature whatsoever of any contract, purchase order or obligation that I may have with any agency of the State of Missouri. SECTION I: PROVIDER INFORMATION PROVIDER NAME*‌ DOING BUSINESS AS NAME (DBA)‌ SECTION II: PROVIDER