Get Electronic Funds Transfer (eft) For Provider Payments

This guide provides a clear and supportive overview of how to fill out the Electronic Funds Transfer (EFT) for Provider Payments form online. By completing this form, providers can enroll in direct deposit for their Fee-For-Service payments, allowing for smoother transactions.

Follow the steps to complete your EFT authorization form effectively.

1. Click ‘Get Form’ button to obtain the form and access it for filling out.
2. In Section A, provide your provider information. Begin with entering your complete legal name as filed with Alameda Alliance for Health.
3. Next, input your Provider Identifier National Provider ID (NPI), or Group NPI if applicable.
4. If you operate under a different name, please enter your Doing Business As (DBA) name.
5. Provide your Provider Identifier, either the Tax Identification Number (TIN) or Employer Identification Number (EIN). Only one TIN can be used per form.
6. Fill in your Provider Contact Name—this should be the person handling EFT issues in your office.
7. Enter your contact person's telephone number, followed by an email address for communications.
8. Complete your provider address details, including city, state, and zip code.
9. Next, provide the name of your authorized agent, along with their telephone number and address.
10. Then, input the financial details in Section B. Start with the Financial Institution Routing Number, which can be found on the bottom of your check.
11. Enter your Provider Account Number with the financial institution ensuring it includes any leading zeros.
12. Specify the type of account you will use to receive EFT payments (either checking or savings).
13. Next, provide the official name of your financial institution and their address.
14. In Section C, authorize your EFT by signing the form and ensuring that your signature matches that of the account owner or authorized representative.
15. Finalize your application by reviewing all the details to confirm they are complete and legible, and attach a voided check or a notarized letter from your bank.
16. Submit your completed form via mail, fax, or email to Alameda Alliance for Health as instructed in the form.

Enroll in Electronic Funds Transfer (EFT) today to streamline your provider payments.