Get Electronic Bfunds Transferb Authorization Bformb With Bb - Caloptima - Caloptima

Filling out the Electronic Funds Transfer Authorization Form with CalOptima is an essential step for providers looking to manage their payments electronically. This guide will walk you through the process of completing the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the Electronic Funds Transfer Authorization Form and open it in your preferred editor.
2. Identify the action you are taking by selecting ‘New’, ‘Change’, or ‘Term’ at the top of the form. Each option serves a different purpose: 'New' for new enrollments, 'Change' for updating account information, and 'Term' for terminating your EFT authorization.
3. Fill in the provider information, including the legal business name, CalOptima Provider ID, National Provider Identifier (NPI), and Federal Tax Identification Number. Make sure to attach a copy of your W-9 form.
4. Enter the service address, which should be the actual practice location (PO Box is not acceptable). Include the office contact name, title, email address, phone number, and fax number.
5. For a change or termination, briefly explain the reason in the provided field.
6. Input your bank details, including the bank name and full address. Ensure you validate the routing number with your financial institution.
7. Fill in the account number and choose the type of account (Checking or Savings). Only select one type.
8. Certify that the information you provided is accurate. This requires the provider to sign the form and include the date. A notarization by a notary public is required for the signature.
9. Finally, mail the completed form to the address specified on the form: CalOptima Provider Enrollment Unit, PO Box 11033, Orange CA 92856. After submission, expect to receive an acknowledgment letter prior to your first electronic payment.

Complete your Electronic Funds Transfer Authorization Form online today for efficient payment processing!