Get Anthem Bc-bs Era Eft Enrollment.doc

Filling out the Anthem BC-BS ERA EFT Enrollment document is a crucial step for providers seeking to implement electronic remittance advice and electronic funds transfer services. This guide will provide a clear and supportive overview of each section of the form, ensuring a smooth online completion process.

Follow the steps to successfully complete your enrollment form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the provider name in the designated field. Make sure to provide the correct and complete name of the facility.
3. Enter the Tax Identification Number, ensuring that it accurately matches the provider's registered information.
4. Provide the physical address, including the street, city, state, and zip code, making sure to double-check for accuracy.
5. In the 'Contact Name' field, enter the name of the individual designated as the primary contact. Include their title and phone number.
6. Select the method you will use to translate or print the ERA file by checking one of the provided boxes.
7. Authorize the implementation of the requested services by acknowledging the agreement stated in the form, ensuring you understand all responsibilities outlined.
8. A duly authorized representative, typically the CEO or CFO, must print their name, sign the form, and include their title, date of signing, and phone number.
9. Complete the Direct Deposit Authorization section, providing the necessary bank account information, and ensure an authorized signer executes the form.
10. Attach any required documents, such as a voided check or deposit slip, as well as a copy of each explanation of payment that displays a unique payee ID number.
11. Finally, save your changes, download a copy for your records, and print or share the completed form as necessary.

Start completing your Anthem BC-BS ERA EFT Enrollment form online today!