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Get Regence Provider Eftach Form
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How to fill out the Regence Provider EFT/ACH Form online
Filling out the Regence Provider EFT/ACH form online is a straightforward process that ensures your payments are processed efficiently. This guide provides detailed instructions to assist you in completing each section of the form, ensuring all necessary information is provided.
Follow the steps to complete the form effectively.
- Press the ‘Get Form’ button to access the document and open it in your preferred editor.
- Begin with Section 1, where you will input your contact information. Fill in the provider organization name, date, tax identification number, and indicate any additional information needed for your EFT setup. Remember to check the box if you want to set up all National Provider Identifiers (NPI) related to the above tax ID. Complete the company street address, city, phone number, fax number, EFT contact name, email address, state, and ZIP code.
- Proceed to Section 2 to provide bank account information. Ensure that the account designated for EFT is a checking account, not a savings account. Fill in the depository/bank name, branch, city, state, routing/ABA number, ZIP code, and account number.
- Select the request type by indicating whether it is a new request or a change to an existing bank account. Attach a voided check in the designated space, ensuring the name, address, account, and routing numbers are visible. Note that bank deposit tickets, bank statements, and other forms will not be accepted.
- Review the authorization statement confirming your understanding of the electronic funds transfer process. Sign and date the form as required. If a co-signer is needed on the account, include their signature and date as well.
- Once you have filled out all sections accurately, save your changes. You can download, print, or share the form as needed before submitting it via email to eft@regence.com or FAX to 1 (888) 875-6905.
Complete your documents online quickly and easily.
The timely filing limit for Regence claims is generally 180 days from the date of service. This requirement aims to ensure the efficiency of claims processing and payment. Submitting the Regence Provider Eftach Form within this time frame will help you receive timely reimbursement for your services. Familiarizing yourself with this limit is beneficial for maintaining a healthy revenue cycle.
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