Get Eft Change/cancel Authorization Form - Healthpartners

The EFT Change/Cancel Authorization Form is essential for managing your electronic banking information with HealthPartners. This guide will help you navigate the form online, ensuring a smooth process for submitting changes or cancellations.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate the type of request by selecting either ‘CHANGE’ or ‘CANCEL’. Remember that a separate form is required for each request.
3. Fill in the company information: enter the Company Name and Tax Identification Number (TIN). This identifies the business associated with the EFT transactions.
4. Provide the contact details by filling out the Company Contact Name, Contact Phone Number, and Contact E-Mail Address. This information ensures HealthPartners can reach you if needed.
5. Complete the Current Account section: enter the Depository Institution (Bank) Name, Routing Transit Number/ABA #, and Account Number. If you are canceling an account, include the Cancellation Date.
6. If changing accounts, fill in the New Account section with the new Depository Institution (Bank) Name, Routing Transit Number/ABA #, Account Number, Account Type, and Effective Date.
7. Review the EFT Worksheet where you specify which organizations the EFT change or cancellation will apply to. Attach this worksheet as required.
8. An Authorized Requester must sign the form. Include the signature, date, legibly print the name and title of the authorized person.
9. Finalize your document; ensure all sections are completed accurately before submitting.
10. Once reviewed, you can save changes, download, print, or share your completed form as instructed.

Complete your EFT Change/Cancel Authorization Form online today to keep your banking information up to date.