Get 402 471 9717

Filling out the 402 471 9717 form online is an essential step for Medicaid providers in Nebraska to enroll for ACH/EFT payments. This guide will provide you with clear, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the Medicaid ACH/EFT enrollment form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin filling out the 'Provider (Vendor) Information' section. This includes entering your name and address. Make sure you provide accurate and current information.
3. Next, fill in the Medicaid Provider Number and the National Provider Identifier (NPI) numbers. Both provider numbers are required for the process.
4. Continue with the 'Financial Institution Information' section. Enter the name and address of your financial institution. This is crucial for processing payments.
5. Provide the Nine Digit Routing Transit Number and Deposit Account Number for accurate banking transactions.
6. List the type of account you are using; choose between checking or savings. If your bank is located outside of the United States, check the corresponding box.
7. Enter your contact information, including your phone number and email address, ensuring you can receive any communication related to your enrollment.
8. In the signature section, both the vendor and a bank representative must sign to verify the information provided. Make sure to date the signatures.
9. Review all your entries for accuracy. Once satisfied, save your changes to the form, and you can then download, print or share it as needed.

Take the next step in your Medicaid provider enrollment by completing the 402 471 9717 online today.