Get Optum Eps Eft User Authorization Agreement

Filling out the Optum Eps Eft User Authorization Agreement online is a straightforward process that enables providers to enroll for electronic payments and statements. This guide will walk you through each section of the form to ensure a smooth enrollment experience.

Follow the steps to complete the enrollment process effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the Provider Information section, fill in the provider name, street address, city, state or province, and zip code or postal code. Note that P.O. Boxes are not accepted for the street address.
3. In the Provider Identifiers Information section, provide the provider's federal tax identification number (TIN) or employer identification number (EIN) and the national provider identifier (NPI). Choose the appropriate provider type by selecting from the listed categories.
4. Complete the Provider Contact Information by entering the name, telephone number (including extension), and email address of the primary contact person.
5. If desired, fill in the secondary provider contact information. Note that these fields are optional but must be completed if added.
6. In the Financial Institution Information section for your TIN, input the financial institution's name, address, telephone number, routing number, account type (checking or savings), and account number.
7. If additional bank information for your NPI is required, repeat the same steps as in step-6 for the NPI section.
8. In the Submission Information section, indicate the reason for submission (new enrollment or change enrollment). Include either a voided check or a bank letter as verification documentation.
9. Provide the required signatures in the Authorized Signature section, including the written signature and printed name of the individual submitting the enrollment.
10. Upon completing the form, save your changes, and if needed, download, print, or share the completed form.

Start your enrollment process today by completing the Optum Eps Eft User Authorization Agreement online.