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Get Electronic Funds Transfer (eft) Authorization Agreement - Mhnet
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How to fill out the Electronic Funds Transfer (EFT) Authorization Agreement - MHNet online
Enrolling in Electronic Funds Transfer (EFT) provides a secure and faster method for receiving payments. This guide will help you navigate the necessary steps to complete the Electronic Funds Transfer (EFT) Authorization Agreement - MHNet effectively and efficiently.
Follow the steps to complete your EFT enrollment form.
- Press the ‘Get Form’ button to access the Electronic Funds Transfer (EFT) Authorization Agreement - MHNet and open it in the online editor.
- Complete the provider information section, entering your Name, Address, City, State/Province, and ZIP/Postal Code. Fields with an asterisk (*) are mandatory.
- In the provider identifiers section, fill in your Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) and your National Provider Identification Number (NPI).
- Provide your contact information, including the Provider Contact Name, Telephone Number, Fax Number, and Email Address, ensuring all required fields are filled out.
- Enter your Financial Institution's Name and Address, including City, State/Province, and ZIP/Postal Code. Include the Financial Institution Routing Number and Type of Account (Checking or Savings).
- Specify your Provider’s Account Number at the Financial Institution. In the 'Account Number Linkage to Provider Identifier' section, select whether you prefer to link payments by Provider TIN or NPI.
- Select your reason for submission from the provided options (New Enrollment, Change Enrollment, Cancel Enrollment) in the submission information section.
- Read and sign the authorization agreement. Include your written signature, printed name, printed title, and submission date.
- After completing all sections, review the form for accuracy, ensuring all fields are filled as required. Save your changes.
- Finally, submit the completed form via email to coventryeftrequest@cvty.com or fax it to 717-541-5991.
Start completing your Electronic Funds Transfer (EFT) Authorization Agreement online today to streamline your payment process.
EFT transactions typically take 48 72 hours to settle.
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