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How to fill out the ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION online
This guide provides clear instructions on how to complete the ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION. Designed to support users regardless of their prior experience, it outlines the necessary steps to ensure successful online submission.
Follow the steps to complete your EFT authorization form.
- Press the ‘Get Form’ button to access the electronic funds transfer authorization form and open it in your online environment.
- In Part I, select the reason for submission by checking the appropriate box for either a new EFT authorization or a revision to current authorization. If applicable, check the box indicating that EFT payment is being made to the Home Office of Chain, and ensure to attach the required authorization letter.
- In Part II, provide the required identification data including your legal business name, tax identification number (either SSN or EIN), and National Provider Identifier (NPI). Ensure that these details match the information registered with Medicare.
- In Part III, fill in the depository information. This includes your bank's name, address, city, state, zip code, telephone number, and the account's routing number. Specify whether it is a checking or savings account, and be sure to include the deposit account number.
- Complete Part IV by entering the contact person's information, which may include their name, telephone number, address, and email address.
- In Part V, provide your authorization by filling in the contractor's name, signing as the authorized representative, and dating the form. Ensure the signature matches the one on file regarding the Medicare enrollment application.
- Finally, review all the provided information for accuracy. Once confirmed, save any changes, download a copy for your records, and print the completed form if needed for mailing. Follow the instructions for sending the form to the designated Medicare contractor.
Complete your EFT authorization form online now for seamless payment processing.
To conduct an EFT transfer, first complete your ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION, including necessary bank details. Once authorized, use your bank’s online platform or mobile app to initiate the transfer. Follow the prompts to specify the amount and confirm the transaction, making sure to review all details before submission.
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