Get Echo Eft And Era Enrollment Form 2022-2026

This guide provides clear and comprehensive instructions on how to complete the ECHO EFT and ERA Enrollment Form online. By following these instructions, users will be able to efficiently fill out the necessary information for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) enrollment.

Follow the steps to complete your enrollment form online.

1. Click ‘Get Form’ button to access the enrollment form and open it on your device.
2. Choose your enrollment option by selecting one of the Form Select options: EFT & ERA, EFT Only, or ERA Only.
3. Fill out your provider information, including the legal name of the institution or practice, street address, city, state, and ZIP code.
4. Provide your provider identifiers. Enter your Federal Tax Identification Number (TIN), and indicate if you possess a National Provider Identifier (NPI). If yes, include your NPI number.
5. If you selected EFT or both EFT and ERA, fill in the contact details for your provider's office, including a contact name, telephone number, and email address.
6. For the financial institution section, enter the official name of your financial institution, routing number, type of account, and your account number.
7. If applying for ERA, complete the remittance advice information, including preference for aggregation of remittance data and method of retrieval.
8. Provide your vendor and clearinghouse information, if applicable, by filling in the official names and contact details.
9. In the submission section, indicate the reason for submission (new, change, or cancel), print your name, and include the submission date.
10. Finally, sign the form to signify consent and compliance with all terms and conditions before submitting it to ECHO Health, Inc. through fax, postal mail, or secure email.

Complete your forms online today to ensure smooth processing of your enrollment.