Get Ach Information Form

The Ach Information Form is essential for the processing of automated clearinghouse payments. This guide provides clear, step-by-step instructions to help users navigate and complete the form online efficiently.

Follow the steps to complete the Ach Information Form online.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editor.
2. Begin by providing the medical provider information. Fill in the provider number, name, and address. Ensure that all information is accurate to avoid delays.
3. Next, enter the contact person's name and their telephone number for further communication regarding the payment.
4. Proceed to the agency information section. Here, input the name along with the designated contact person's name and telephone number for the DOL Federal Black Lung Program.
5. In the financial institution information section, fill in the name and address of the bank or financial institution handling the transactions.
6. Complete the ACH coordinator's name and telephone number provided by the financial institution.
7. Enter the nine-digit routing transit number, depositor account title, and account number. Ensure that you select the appropriate account type, either Checking or Savings.
8. Finally, have a representative sign the form and include their title. Review the entire form to ensure completeness, as incomplete forms may cause processing delays.
9. Once all information is filled out correctly, you can save changes, download, print, or share the form as needed.

Complete your Ach Information Form online today for efficient payment processing.