Get Electronic Remittance Advice (835) And Eft Enrollment Form

The Electronic Remittance Advice (835) and EFT Enrollment Form is essential for providers wishing to receive electronic payments and remittance advice. This guide will assist you in completing the form online, ensuring all necessary information is accurately provided.

Follow the steps to complete your form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Indicate your enrollment preferences by checking one of the options: 'EFT and 835/ERA' or 'EFT only with paper remittance'.
3. Provide the name of your facility, group, or practice exactly as it appears on your bank account in the designated field.
4. Enter your remit/mailing address, ensuring it is accurate for correspondence.
5. Specify the anticipated start date for electronic remittance in the provided field.
6. Include your Tax ID number, which is necessary for identification and processing.
7. Fill in the contact name of the person managing this enrollment, along with their phone number and email address for communication.
8. Input your bank routing number and bank account number that will receive the electronic funds.
9. List the name and location of your bank.
10. Identify the entity associated with the tax ID provided in a dedicated field.
11. Provide the name of your trading partner or clearinghouse, such as 'Office Ally'.
12. If applicable, furnish the contact name and telephone number of the trading partner.
13. Sign and date the form to authorize the designated person to perform necessary functions.
14. Once completed, save your changes, and download, print, or share the form as needed.

Complete your Electronic Remittance Advice (835) and EFT Enrollment Form online today.