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  • Eps Eft User Authorization Agreement

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Account Number Linkage to Provider Identifier: National Provider Identifier (NPI) Financial Institution Information for your NPI: This financial Institution section will collect banking information for payments made to your provider/organizational NPI. An NPI Bank Account is only required if you want deposits directed to an account different than the one assigned at the TIN level. *Financial Institution Name: Financial Institution Address *Street: *City: *State/Province: *Zip Code/Postal Co.

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Electronic Payments and Statements (EPS) is a practical solution to provide electronic delivery of payments and electronic remittance advices (ERA) to physicians, hospitals and other health care professionals.

If you select “Pay Provider”, we will send a payment directly to your provider. If you select “Reimburse Myself”, we will send payment to you. Simply enter a few pieces of information about your claim, including date of service, provider, amount, who received the service, your service category and type.

Please fax the signed enrollment form, a copy of a bank letter or voided check(s) and your completed W-9 to Attn: Processing Manager (800) 765-6766. Or, if you prefer, you can mail all the required and signed forms to: Optum EPS, Attn: Processing Manager, P.O.Box 30777, Salt Lake City, UT 84130-0777.

Use it at the pharmacy, pay at the doctor's office or write your payment card number on your provider bill. Just remember to keep your receipt, because transactions may have to be validated or substantiated per IRS guidelines.

A health care payment delivery solution designed to boost efficiency and improve cash flow, Optum Pay® empowers providers to choose how to receive payments across a broad network of health care payers.

With Electronic Funds Transfer (EFT), Medicare can send payments directly to a provider's financial institution whether claims are filed electronically or on paper. All Medicare providers may apply for EFT.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232