Get Eft Electronic Funds Transfer Authorization ... - Health Net

Filling out the EFT Electronic Funds Transfer Authorization form is essential for ensuring efficient payment processing with Health Net. This guide provides step-by-step instructions to help you navigate and complete the form accurately, facilitating smoother transactions.

Follow the steps to fill out the form correctly:

1. Press the ‘Get Form’ button to access the EFT Electronic Funds Transfer Authorization form and open it in your preferred editor.
2. In the 'Provider Information' section, fill in the provider name, address (including street, city, state, and zip code), ensuring all details are accurate and complete.
3. Next, provide the 'Provider Identifiers Information' by entering the Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) and the National Provider Identifier (NPI). Both numbers must be formatted correctly.
4. In the 'Provider Contact Information' section, enter the name, title, telephone number, fax number, and email address of the individual authorized to communicate with the EDI staff regarding EFT transactions.
5. Complete the 'Financial Institution Information' by entering the financial institution's name, routing number, and selecting the type of account (checking or savings). Additionally, input your account number, ensuring it does not exceed 17 digits.
6. Select the appropriate option in the 'Account Number Linkage to Provider Identifier' indicating how the account is to be linked, choosing either the Provider Tax Identification Number or National Provider Identifier.
7. In the 'Submission Information' section, indicate your reason for submission by checking the relevant box (new enrollment, change enrollment, cancel enrollment, etc.). If applicable, include any supporting documentation like a voided check or bank letter.
8. Lastly, provide the authorized signature of the individual submitting the enrollment, along with their printed name, printed title, and the submission date. Specify the requested EFT start, change, or cancel date.
9. Once all fields are accurately completed, you can save changes, download the form, print it, or share it as needed. Remember to fax the completed form to 1-800-677-4147.

Complete your EFT Electronic Funds Transfer Authorization form online today for efficient processing.