ContractEft Authorization Agreement • June 21st, 2013 • Montana
This EFT Authorization Agreement must be fully completed, signed and returned via fax to Blue Cross and Blue Shield of Montana (BCBSMT) Electronic Commerce Services at 312-946-3500 with the required documentation as noted below.
ContractEft Authorization Agreement • February 21st, 2012 • New Mexico
*This EFT Authorization Agreement form is for providers submitting Medicare Secondary or Crossover claims. It is to be used ONLY by non-contracting providers located outside of the Illinois, Montana, New Mexico, Oklahoma, Texas Blue Plan states and their contiguous counties.
PLEASE FILL IN THE FOLLOWING INFORMATION**Eft Authorization Agreement • April 5th, 2019
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • July 19th, 2010
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • July 29th, 2014
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • January 16th, 2008
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • May 23rd, 2016
Electronic Funds Transfer (EFT) Authorization AgreementEft Authorization Agreement • June 21st, 2013 • Illinois
This EFT Authorization Agreement must be fully completed, signed and returned via fax to the Blue Cross and Blue Shield of Montana (BCBSMT) Electronic Commerce Center at 312-946-3500.
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • April 20th, 2018
EFT AUTHORIZATION AGREEMENT FOR RECURRING DIRECT PAYMENTSEft Authorization Agreement • February 3rd, 2017
AGREEMENT FOR PRE-ARRANGED CHARGESEft Authorization Agreement • March 19th, 2024
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • November 11th, 2024
UMP Medicare Classic with Part D (PDP) Late Enrollment Penalty Authorization for Electronic Funds Transfer (EFT)Eft Authorization Agreement • September 11th, 2024
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • June 16th, 2014
electronic funds (EFT) authorization agreementEft Authorization Agreement • May 1st, 2009
DIAMONDHEAD WATER & SEWER DISTRICTEft Authorization Agreement • June 27th, 2013
Applicant's Name (As Shown on Bank Records) Phone# Print Account Holders Name(s) as Shown on Check Addresses as shown on Bank Records City St Zip
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • June 16th, 2015
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • April 3rd, 2018
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • August 22nd, 2012
I/we hereby authorize LogistiCare Solutions, LLC (“The Company”) to initiate electronic credit entries to the financial institution and account indicated below. I/we further authorize “The Company” to initiate electronic debit entries to the account listed below to correct any errors. This authority is to remain in full force and effect until “The Company” has received written notification to terminate the agreement. All changes must be submitted in writing and may require a new EFT agreement.
ContractEft Authorization Agreement • August 11th, 2021
WEA ESP Pre-retired Dues115 East 22nd Street, Cheyenne, WY 82001FAX: 307-778-8161 Phone: 307-634-7991 ext. 102 Email: lbottom@wyoea.org EFT Authorization Agreement for Prearranged Payment of Dues FormNOTE: ESP Pre-retired dues are only paid once in a lifetime!Local Name: _Name: SSN4 (last four digits only): Address: Cell Phone: City State Zip: Home Email: Work Location (building name): OPTION 1: EFT Account pulling from:Membership Type/Fund/Obligations: □ Checking or □ Savings Fund Name Membership Type Annual Dues This EFT authorization will not be accepted unless a voided personal check is attached. NEA ESP Pre-retired - RT-9-6 $180.00 WEA ESP Pre-retired - RT-9-6 $ 50.00 LEA ESP Pre-retired – RT-9-6 $ 50.00 Total Obligation $280.00 • Total amount due can be divided into 2-6 payments,provided the total obligation is paid in full no later than July 10th.• Deductions
Louisiana Medicaid Direct Deposit (EFT) Authorization AgreementEft Authorization Agreement • October 13th, 2020
• If the individual provider is doing group billing only, then an EFT form should not be completed for the individual. Instead, an EFT form should be submitted (or already on file) only for the business or entity which the individual is linked to.
EFT AUTHORIZATION AGREEMENTEft Authorization Agreement • November 7th, 2018
This agreement will remain in effect until SCPW has received notice from the undersigned customer only and has been provided reasonable opportunity to take action. To ensure accuracy, a voided check or a bank letter must accompany this agreement. This service will be discontinued if SCPW receives two nonsufficient funds notifications. SCPW will not be responsible for any overdraft or insufficient charges assessed to the bank account due to lack of funds.
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • July 6th, 2015
New Set Up ☐ Cancellation ☐ Change of Information ☐Eft Authorization Agreement • June 6th, 2017
VENDOR INFORMATION: Legal Name Company Address Street Number Street Name Suite/Floor/Unit Unit City Province Postal Code Remittance Address (if different from Above) Street Number Street Name Suite/Floor/Unit Floor City Province Postal Code Remittance Contact Name: Title Remittance Email Address* Phone Number *The Remittance email detailing the invoice number, invoice amount paid, date of the payment and the total dollar value of the payment will be sent to the remittance email address specified above.
PREMCO FINANCIAL CORPORATIONEft Authorization Agreement • September 24th, 2009
This EFT Authorization Agreement must be fully completed, signed and returned via U.S. Mail or fax to: Blue Cross and Blue Shield of Texas (BCBSTX)Eft Authorization Agreement • February 21st, 2012 • Texas
This enrollment form will be used to activate EFT for both BCBSTX commercial payments and BCBSTX Medicaid payments (if you are a BCBSTX Medicaid network provider).
ContractEft Authorization Agreement • January 30th, 2020
*Please print and complete this form and return to our office by mail or email (info at bottom of page). Questions? Call the office or email Carla (info at bottom of page.) Thank you!
PREMCO FINANCIAL CORPORATIONEft Authorization Agreement • May 26th, 2009
EFT AUTHORIZATION AGREEMENT FOR LOCAL JURISDICTIONSEft Authorization Agreement • September 19th, 2017
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENTEft Authorization Agreement • April 22nd, 2016
EFT AUTHORIZATION AGREEMENTEft Authorization Agreement • November 7th, 2018
This agreement will remain in effect until SCPW has received notice from the undersigned customer only and has been provided reasonable opportunity to take action. To ensure accuracy, a voided check or a bank letter must accompany this agreement. This service will be discontinued if SCPW receives two nonsufficient funds notifications. SCPW will not be responsible for any overdraft or insufficient charges assessed to the bank account due to lack of funds.
EFT AUTHORIZATION AGREEMENTEft Authorization Agreement • June 27th, 2017
This Power of Attorney and authorization is to remain in full force and effect for this account and all of my/our subsequent accounts until AGILE has received written notification from me/us of its termination in such time and in such manner as to afford AGILE and DEPOSITORY a reasonable opportunity to act on it, but in no event will occur later than three business days prior to the scheduled date of transaction. I/We further understand that sufficient funds must be available at the time each transfer is processed. In the event that there are insufficient funds, AGILE will charge up to the maximum NSF fee permitted by law. If this authorization is for a Corporation or LLC, the undersigned is an officer of said Corporation or a member of the LLC and authorized to execute this authorization on behalf of the Corporation or LLC.
DIAMONDHEAD WATER & SEWER DISTRICTEft Authorization Agreement • June 27th, 2013
Applicant's Name (As Shown on Bank Records) Phone# Print Account Holders Name(s) as Shown on Check Addresses as shown on Bank Records City St Zip
EFT AUTHORIZATION AGREEMENTEft Authorization Agreement • June 18th, 2013 • Delaware
The Suppler named below agrees to participate in the Electronic Funds Transfer (“EFT”) Program conducted by Banfield Pet Hospital (“Buyer”) as described below:
EFT AUTHORIZATION AGREEMENTEft Authorization Agreement • November 7th, 2018
This agreement will remain in effect until SCPW has received notice from the undersigned customer only and has been provided reasonable opportunity to take action. To ensure accuracy, a voided check or a bank letter must accompany this agreement. This service will be discontinued if SCPW receives two nonsufficient funds notifications. SCPW will not be responsible for any overdraft or insufficient charges assessed to the bank account due to lack of funds.
