Common Contracts
2 similar Electronic Funds Transfer (Eft) Authorization Agreement contracts
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • July 31st, 2019
REASON FOR SUBMISSION Change to Current EFT (i.e. account or bank changes) ⃝ Individual ⃝ Organization INDIVIDUAL PROVIDER/ORGANIZATION NFORMATION Individual Provider/Organization Legal Business Name Doing Business as Name (DBA) Street City State Zip Code/Postal Code - Medicaid Provider Number National Provider Identifier (NPI) Designate Tax Identification Number (TIN) ⃝ SSN (individual) ⃝ EIN (organization) SSN - - EIN - ORGANIZATION/INIDIVIDUAL PROVIDER EFT CONTACT INFORMATION Provider Contact Name Telephone Number Extension Email Address FINANCIAL INSTITUTION INFORMATION Financial Institution Name Financial Institution Address City State Zip Code/Postal Code - PROVIDER’S ACCOUNT NUMBER WITH FINANCIAL INSTITUTION Financial Institution Routing Number (Nine di
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • July 31st, 2019
REASON FOR SUBMISSION Change to Current EFT (i.e. account or bank changes) ⃝ Individual ⃝ Organization INDIVIDUAL PROVIDER/ORGANIZATION NFORMATION Individual Provider/Organization Legal Business Name Doing Business as Name (DBA) Street City State Zip Code/Postal Code - Medicaid Provider Number National Provider Identifier (NPI) Designate Tax Identification Number (TIN) ⃝ SSN (individual) ⃝ EIN (organization) SSN - - EIN - ORGANIZATION/INIDIVIDUAL PROVIDER EFT CONTACT INFORMATION Provider Contact Name Telephone Number Extension Email Address FINANCIAL INSTITUTION INFORMATION Financial Institution Name Financial Institution Address City State Zip Code/Postal Code - PROVIDER’S ACCOUNT NUMBER WITH FINANCIAL INSTITUTION Financial Institution Routing Number (Nine digits) Provider’s Account Number with
