Get Change Healthcare Epayment Enrollment Authorization Form

This guide will assist you in completing the Change Healthcare Epayment Enrollment Authorization Form online. Following these clear steps will ensure a smooth and accurate enrollment process.

Follow the steps to successfully complete the enrollment form.

1. Click ‘Get Form’ button to access the Change Healthcare Epayment Enrollment Authorization Form and open it in your preferred online editor.
2. Provide your basic information in the required fields. This includes your provider name, address, and federal tax identification number. Ensure accuracy to avoid delays in processing.
3. Attach necessary documentation, such as an original signature, a government-issued ID, and a bank authorization letter or voided check. All forms must include an original signature; electronic signatures are not acceptable.
4. Complete the financial institution information section. This should include the contact name, address, and phone number of your financial institution as well as account details.
5. If applicable, indicate any changes to your bank account information, ensuring to confirm the last EFT deposit amount with Change Healthcare.
6. Review your entries for accuracy and completeness before submission. Double-check all attached documents to ensure they are included.
7. Sign the form at the designated area, acknowledging that all information provided is accurate and complete.
8. Submit the completed form by email as a PDF attachment to EFTEnrollment@changehealthcare.com or fax it to 615.238.9615. Make sure to keep a copy for your records.

Start completing your Change Healthcare Epayment Enrollment Authorization Form online now for efficient enrollment!