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Filling out the Tricare4u Electronic Funds Transfer (EFT) Authorization Form is a straightforward process that ensures timely payments for services provided to Tricare for Life beneficiaries. This guide will outline each section of the form to help users complete it efficiently.

Follow the steps to successfully complete your EFT form.

1. Click ‘Get Form’ button to access the form and open it in your document editor.
2. In Part I, select the reason for submission by marking the appropriate box: new EFT authorization, revision to current authorization, or EFT termination request.
3. In Part II, provide the required identification data. Enter the legal business name as reported to the IRS in Line 1, followed by the provider’s or supplier’s information in subsequent lines. Include the tax identification number in Line 5.
4. For Line 6, choose either the Tax ID option for all locations under this Tax ID or the Specific Group NPI & Pay To/Payment Location(s) option and specify accordingly.
5. In Part III, provide depository information. Enter your bank or financial institution's name and address, your account details, and include the nine-digit routing number along with the type of account.
6. In Part IV, fill in the contact person's details who is responsible for this authorization agreement, including their name and contact information.
7. In Part V, sign and date the form to authorize the Wisconsin Physicians Service Insurance Corporation to manage the EFT. Ensure that the official name and title are printed where required.
8. Once all sections are completed and reviewed, save changes to your document. You may then download, print, or share the form as needed before mailing it to the designated address.

Complete your Tricare4u form online today to streamline your payment process.