Get Aetna Era Enrollment Form

The Aetna Era Enrollment Form is essential for managing electronic funds transfers for medical capitation. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently, ensuring your enrollment process is smooth.

Follow the steps to successfully complete the enrollment form.

1. Press the ‘Get Form’ button to access the Aetna Era Enrollment Form and open it for editing.
2. In Section A, provide the required practice information, including the name, tax ID number (TIN), contact name, email address, telephone number, national provider identifier (NPI), and fax number. Ensure all fields are legible and complete to avoid delays.
3. Also in Section A, fill in the primary service address and primary billing address accurately.
4. In Section B, complete the EFT-direct deposit/banking information. You must provide your bank name, address, routing number (nine digits), account number, and select the account type (savings or checking). A voided check or a letter from your bank is required for new or changed accounts.
5. If applicable, provide the previous bank details in Section B, including the previous bank name, previous address, previous routing number, previous account number, and account type.
6. In Section C, read the authorization agreement carefully. Sign and date the document as an authorized health care professional. Obtain a signature from a supervisor-level authorized personnel, including their title and date.
7. After completing all sections, review the form for accuracy. Save any changes made, then print or share the form as required.

Complete your documents online to ensure timely processing and avoid delays.