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How to fill out the ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION online
Filling out the Electronic Funds Transfer (EFT) Authorization Form is essential for ensuring timely and accurate payments. This guide will help you understand each section of the form and provide step-by-step instructions for completing it online.
Follow the steps to complete your EFT Authorization Form online.
- Press the ‘Get Form’ button to access the EFT Authorization Form and open it in the editor.
- In Part I, indicate your reason for submission by checking the appropriate box: New EFT Enrollment, Change to Current EFT Enrollment, or Cancel EFT Enrollment. If applicable, attach a letter authorizing EFT payments to the home office of a chain organization.
- In Part II, provide the Account Holder Information. Enter the legal business name of the provider, supplier, or indirect payment procedure (IPP) biller, followed by the address, Tax Identification Number (TIN), and any Medicare identification numbers, including the National Provider Identifier (NPI). Ensure you provide accurate details for verification.
- In Part III, fill in the Financial Institution Information. Include the name, address, and contact details of your financial institution, followed by the routing number and your account number. Indicate whether the account is a checking or savings account. Supporting documentation must be provided to verify the account.
- In Part IV, complete the Contact Person section with the name, title, and contact details of a person who can answer questions regarding this EFT submission.
- In Part V, provide your authorization. Sign and date the form in black or blue ink. The form must be signed by an authorized representative as indicated in the CMS-855 Medicare enrollment application.
- Once all sections are completed, review the form for accuracy. Save your changes, and you can choose to download, print, or share the completed form as needed.
Start your submission process and complete your EFT authorization form online now.
To perform an EFT transfer, first, ensure you have completed the necessary EFT authorization form with your banking details. Next, initiate the transfer by either contacting your bank or using their online services, entering the required information for the sender and recipient. Following these steps allows you to manage your electronic funds transfer (EFT) authorization effectively and safely.
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