Get Ihcp Eft Enrollment Form

Filling out the Ihcp Eft Enrollment Form online is a straightforward process that enables healthcare providers to establish electronic payment options for claims. This guide will walk you through each section of the form to ensure a smooth completion.

Follow the steps to successfully complete the Ihcp Eft Enrollment form:

1. Click 'Get Form' button to obtain the form and open it in the document editor.
2. Enter the legal name of the institution, corporate entity, practice, or individual provider in the Provider Name field.
3. Provide the street address of the provider’s home office in the Street field.
4. Input the city associated with the provider’s home office address.
5. Enter the two-character state code associated with the provider’s home office in the State/Province field.
6. Complete the ZIP Code/Postal Code field with the U.S. postal-zone code (ZIP + 4) corresponding to the provider's home office.
7. Fill in the federal Tax Identification Number (TIN) or Employer Identification Number (EIN) used to identify the business entity.
8. Input the National Provider Identifier (NPI), which is a unique identification number for registered healthcare providers.
9. Enter the name of a contact person in the provider’s office who handles EFT issues in the Provider Contact Name field.
10. Provide the telephone number associated with the EFT contact person.
11. Fill in the electronic mail address of the EFT contact person.
12. Indicate whether the account belongs to a provider agent (billing agency) by selecting 'Yes' or 'No'.
13. If applicable, fill out the provider agent information, including agent name, address, and contact details.
14. Enter the official name of the financial institution where payments will be deposited.
15. Provide the contact telephone number at the financial institution.
16. Input the nine-digit routing number of the financial institution.
17. Specify the type of account (checking or savings) that will be used for receiving EFT payments.
18. Enter the account number at the financial institution.
19. Complete the linkage of the account number to the provider's TIN in the designated field.
20. Select the reason for submission by indicating 'New Enrollment,' 'Change Enrollment,' or 'Cancel Enrollment'.
21. Obtain the required authorized signature from the person submitting the enrollment.
22. Provide the printed name and title of the person signing the form.
23. Fill in the submission date.
24. Review all entries for accuracy, save changes, and proceed to download or print the completed form.

Begin filling out the Ihcp Eft Enrollment Form online today for efficient payment processing.