Common Contracts
2 similar Electronic Funds Transfer (Eft) Authorization Agreement contracts
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • November 29th, 2016
Provider Group/IPA Name Tax ID Street City State Zip Provider, IPA or MSO Contact(Please circle one) Phone Fax Email Contact Title MSO Name, if any 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.
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • November 29th, 2016
Provider Group/IPA Name Tax ID Street City State Zip Provider, IPA or MSO Contact(Please circle one) Phone Fax Email Contact Title MSO Name, if any 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.
