Get Eft Enrollment Form - Geisinger Health Plan

Filling out the EFT Enrollment Form for Geisinger Health Plan online can streamline your enrollment process, ensuring that your payment information is accurately submitted. Follow this guide to navigate through the form efficiently.

Follow the steps to complete the EFT Enrollment Form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Enter provider information. This includes the provider name which must match the name on the bank account, and addresses for both primary service and billing. Fill in the street address, city, state/province, and ZIP code/postal code for each address clearly.
3. Provide your provider identifiers. This section includes entering the Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) that matches the records with Geisinger Health Plan, as well as the National Provider Identifier (NPI) if applicable.
4. Complete the provider contact information by detailing the provider contact name, telephone number, email address, and fax number. Ensure all fields are accurately filled out.
5. Detail financial institution information. Include the name and address of your financial institution, ensuring the routing number is correctly noted. This should be a 9-digit routing number found on your check, not on a deposit slip.
6. Indicate the type of account at your financial institution by selecting 'Checking' or 'Savings'. Next, enter your provider’s account number and ensure the account number linkage corresponds with your Provider Tax Identifier Number (TIN).
7. In the submission information section, choose the reason for submission by indicating whether this is a new enrollment, change enrollment, or cancellation of enrollment.
8. Read and agree to the Authorization Agreement for Direct Deposit of Provider Payments. Sign and date the form where indicated to confirm your authorization.
9. After completing all sections, review the form for any errors or omissions, then save your changes. You can now download, print, or share the form as needed before faxing it to the specified number (570-214-1553).

Begin completing the EFT Enrollment Form online today and ensure your provider payments are set up efficiently.