Follow the steps to complete the ERA/EFT Enrollment Form accurately.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by selecting the appropriate enrollment option: New ERA Enrollment, Change ERA Enrollment, New ERA/EFT Enrollment, or Change EFT Enrollment. Mark the checkbox next to your choice.
3. Fill in the Tax Identification Number and National Provider Identification fields with the required information.
4. If applicable, enter your UHIN TP# in the designated field.
5. Complete the Provider Name and Provider Physical Address sections, including City, State, and Zip Code.
6. Authorizations are crucial. Ensure you understand the implications of requesting electronic remittance advice and/or electronic funds transfer.
7. Designate a primary contact person for ERA/EFT in the specified section. This person will be responsible for accessing files.
8. If you work with a billing agent, indicate your agent's involvement by checking the appropriate box and attaching a Release Letter.
9. Provide all relevant contacts that will need access to download ERA files in the ePortal ERA Contact List. Ensure to include names, email addresses, and phone numbers.
10. Proceed to authorize the form. The authorized representative must print their name, sign the document, and include their title and phone number.
11. Fill out the EFT Fund Information section by providing the necessary bank account details, including a voided check copy.
12. The authorized signer for the bank account should print their name, sign the form, and include their title and phone number.
13. After completing all sections, save your changes. You can download, print, or share the form for submission.

Ready to streamline your electronic remittance process? Complete the ERA/EFT Enrollment Form online today!