Claim Payment EXNV Electronic Funds Transfer (EFT) Authorization Agreement ⃝ New ⃝ Change ⃝ CancelElectronic Funds Transfer (Eft) Authorization Agreement • October 25th, 2023
** The EOB for payment will be sent ONLY via email once you enroll to receive claim payment via EFT. If EOB should be sent to a different email, please list a different email here:
COMMONWEALTH OF MASSACHUSETTSElectronic Funds Transfer (Eft) Authorization Agreement • July 28th, 2020
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • November 17th, 2021
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • September 13th, 2017
Provider Information (required) Provider Name Street Address City State ZIP Provider Identifiers Information (required) Provider Federal Tax Identification Number(TIN) or Employer Identification Number (EIN) National Provider Identifier (NPI) Provider Contact Information (required) Provider Contact Name Telephone Number Telephone Number Extension Email Address Authorization Agreement for Automatic Deposits (Automated Clearing House Credits)I, provider name (“PROVIDER”), hereby authorize eClusive, LLC (“COMPANY”) to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to PROVIDER’s checking/savings account(s) indicated below and the bank named below (“BANK”), to credit and/or debit the same account. Financial Institution Information (required) Please provide PROVIDER’s bank account information below. Financial Institution Name Street Address City State ZIP Financial Institution Routing Number Type of Account at Financial Institution C
Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • January 7th, 2021 • Ontario
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 • December 29th, 2021
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 (EFT) authorization agreementElectronic Funds Transfer (Eft) Authorization Agreement • July 27th, 2010
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • April 25th, 2016
*** 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.
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • March 3rd, 2020
The Remittance email detailing the invoice number, invoice amount paid, date of the payment and the total dollar values of the payment will be send to the remittance email address specified above.
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • April 25th, 2011
*** 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.
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • October 7th, 2019
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • December 29th, 2021
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • November 29th, 2016
Provider Name Tax ID □ EIN □ SSN Street City State Zip Provider Contact Phone Fax ** Email ** The EOB for payment will be sent ONLY via email once you enroll to receive claim payment via EFT. If EOB should be sent to a different email, please list a different email here: 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 • December 11th, 2013
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • April 6th, 2023
Berkley Southwest offers an EFT payment option that is efficient and convenient with no installment fees. The EFT pay plan allows your monthly premium payment to be automatically debited from your bank account once enrolled. The premium balance will be split equally over the policy term based on the enrollment date.
Provider InformationElectronic Funds Transfer (Eft) Authorization Agreement • February 3rd, 2014
Reason for Submission O New Enrollment O Change Enrollment O Cancel Enrollment Include with Enrollment Submission O Voided Check O Bank Letter
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • September 13th, 2023
❖ Note: If all steps have not been completed correctly the approval process may be delayed or your application may be denied
ContractElectronic Funds Transfer (Eft) Authorization Agreement • March 22nd, 2011
Shasta-Siskiyou Transport dba: SST Oil FOR OFFICE USE ONLY P.O. Box 990327 • 2370 Wyndham Lane • Redding, CA 96099 Acct #: Phone: 530-241-1167 • Fax: 530-241-7683 Acct Name: Email: www.sstoil.com Entered: Electronic Funds Transfer (EFT) Authorization Agreement ** Please include a voided check with this form. Account Name: Phone: Address: Cell: City: State: Zip: hereby authorizes Shasta-Siskiyou Transport dba: SST Oil its wholly owned subsidiaries and affiliates (Company) entries to customer's bank account indicated below and the bank name below to debit or credit such transactions to such bank account. I would like EFT notifications to be: Faxed to : Emailed to: Bank Name: Contact: Address: Phone: City: State: Zip: Fax: Bank Account #: ABA Routing #: This authority shall remain in effect until terminated upon 15 days written notice by either customer or Company at P.O. Box 990327, Redding, CA 96099. However, the Company
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • March 3rd, 2011
BANKING INFORMATION (Please include a copy of the electronic deposit information on bank letterhead. This is required and the information will be used to verify your bank account information).
ContractElectronic Funds Transfer (Eft) Authorization Agreement • October 21st, 2015
Electronic Funds Transfer (EFT) Authorization Agreement FormElectronic Funds Transfer (Eft) Authorization Agreement • February 18th, 2016
Written Signature of Person Submitting Enrollment: Printed Name of Person Submitting Enrollment: Printed Title of Person Submitting Enrollment:
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • April 23rd, 2024
❖ Note: If all steps have not been completed correctly the approval process may be delayed or your application may be denied
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • May 22nd, 2019
Medicaid Providers must submit this form to receive payment directly into their bank account. The funds can be credited to either a checking or savings account.
Electronic Funds Transfer (EFT) Authorization Agreement InstructionsElectronic Funds Transfer (Eft) Authorization Agreement • September 3rd, 2015
COMMONWEALTH OF MASSACHUSETTSElectronic Funds Transfer (Eft) Authorization Agreement • August 25th, 2020
OKLAHOMA STATE DEPARTMENT OF EDUCATIONElectronic Funds Transfer (Eft) Authorization Agreement • July 8th, 2015
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • January 26th, 2016
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • November 29th, 2011
In order for funds to be transferred electronically from your checking account to Sharp Billing Services, Inc. (Sharp) for payment of your insurance premium, it will be necessary for you to complete the information below and to attach a voided, blank check from the account which you will be using to make your payments. Please note that it is absolutely necessary for the insured to be an owner of the account being used for the EFT payment and for the name as the insured to be upon the account.
Briggs Wellness CenterElectronic Funds Transfer (Eft) Authorization Agreement • May 8th, 2020
GMAC Direct Pay - Electronic Funds Transfer (EFT) Authorization Agreement for GMAC InsuranceElectronic Funds Transfer (Eft) Authorization Agreement • September 28th, 2006
ContractElectronic Funds Transfer (Eft) Authorization Agreement • April 30th, 2013
Electronic Funds Transfer (EFT) Authorization AgreementElectronic Funds Transfer (Eft) Authorization Agreement • July 1st, 2019
By signing this form, I authorize the Department of Health and Human Services to initiate credit entries and to initiate, if necessary, debit entries for any credit entries in error to the checking or savings account indicated above at the financial institution identified above. Credit entries will pertain only to the Department of Health and Human Services payment obligations resulting from Medicaid services rendered by the provider. In the event of excess payment to this bank account, I authorize the Department of Health and Human Services to make an adjusting debit entry to the account up to the amount of the excess payment. Credit entries to the above account are done with the understanding that payment will be from federal and/or state funds and that any false claims, statements or documents or concealments of a material fact, may be prosecuted under applicable federal or state laws. I certify that the information shown is correct and agree to provide thirty (30) days written noti
Electronic Funds Transfer (EFT) Authorization Agreement and Contact InformationElectronic Funds Transfer (Eft) Authorization Agreement • October 18th, 2017
All fields are required. See page 2 for instructions, if needed. Completed forms may be faxed to (855) 854-4570, or scanned and e-mailed to CustomerService@LifeMapCo.com.
