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Get (EFT) Provider Form - UHA

Tion provided on this form will be used to set up your office for Electronic Funds Transfer (EFT). Please complete this form as accurately as possible. If a section is not applicable, write N/A. Mail, Fax or Email your completed form to: UHA Attention: Contracting Services 700 Bishop Street, Suite 300 Honolulu, HI 96813 Email: ContractingServices uhahealth.com Fax: 1-866-572-4383 I. Provider Information Provider Name: (Complete legal name of institution, corporate entity, practice or in.

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