Get Eft Enrollment & Maintenance Form Banking ... - Anthem

This guide provides a comprehensive overview of how to accurately fill out the EFT Enrollment & Maintenance Form for Anthem. Following these steps will help ensure your enrollment is processed smoothly and efficiently.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Indicate your status by checking one of the options: 'Enroll', 'Change/Update', or 'Terminate'. Make sure this section is filled out accurately.
3. Provide the provider name in the designated field. Include your Payee ID number, as listed on the Anthem Provider Remittance, and your Tax ID number.
4. Enter any administrative contact information, including their title and phone number, ensuring contact details are correct.
5. In the banking information section, select the account type by checking either 'Checking' or 'Savings', and attach a voided check or deposit slip as necessary.
6. Fill in the name of your financial institution and include both the Transit (Routing) number and account number in the specified format.
7. An authorized signer on the bank account must print their name, sign the form, and provide their title and phone number. Ensure the date signed is also included.
8. Optionally, provide a fax number for contact. Once the form is complete, save changes, and prepare to fax, email, or mail it to the specified contact details provided.

Complete your documents online today to ensure timely processing.