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Get Electronic Funds Transfer (EFT) Enrollment Application - Securityhealth

Practice information Practice name Street address City EFT contact name Practice tax ID number* State Contact phone ZIP code EFT contact fax EFT contact e-mail address * If the tax ID number listed above applies to more than one practice, enter information on page 3. 2. Account information Name of financial institution Street address City State Phone number Fax number l Account type: Checking ZIP code l Savings l Other specify.

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