Get Meridian Form 30 2013-2025

Filling out the Meridian Form 30 online is a straightforward process designed to facilitate electronic funds transfer enrollments for pharmacies. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently.

Follow the steps to fill out the Meridian Form 30 online seamlessly.

1. Press the ‘Get Form’ button to access the Meridian Form 30, allowing you to edit the form according to your needs.
2. In Part I, indicate the reason for submission by selecting one of the options: New EFT Authorization, Cancel EFT, Revision to Existing Enrollment, or Enroll in Electronic Remittance Advice (ERA).
3. Fill out Part II with your pharmacy or organization's information, including Tax ID, Chain Code/Payment Center ID/NCPDP, Organization Name, Address, City, State, and Zip Code.
4. In Part III, provide your pharmacy or organization contact details, including Name, Title, Email Address, Phone Number, and Fax Number.
5. Move to Part IV for Designation of Depository. Here, enter Bank Name, Account Name, Bank Address, City, State, Bank Contact Name, Bank Contact Phone Number, Routing Transit Number, Bank Account Number, and select Account Type (Checking Account or Savings Account). Remember to attach a voided check.
6. If applicable, complete Part V with Electronic Remittance Advice Information, adding the Contact Name, Contact Phone Number, and Contact Email. Indicate if your pharmacy uses a third party for account reconciliation and provide the requested information.
7. Review the Authorization section, ensuring that you have the authority to enroll the pharmacy, and confirm the accuracy of the provided information.
8. Sign and date the form in the appropriate fields.
9. After completing the enrollment form, save your changes. You can then download, print, or share the form as necessary, or return the completed forms and attachments by fax, email, or mail.

Start completing your Meridian Form 30 online today for efficient enrollment.