Get Instructions For Completing The Authorization Agreement For Eft

This guide provides a clear and comprehensive approach to completing the Instructions For Completing The Authorization Agreement For EFT online. You will find step-by-step guidance tailored to help you navigate the form with ease.

Follow the steps to successfully complete your EFT authorization agreement.

1. Press the ‘Get Form’ button to access the form and open it in the online editor.
2. In Part I, identify the reason for submission by selecting either 'New EFT Enrollment' or 'Change to Current EFT Enrollment'. If your payment accounts to a Chain Home Office, ensure to attach the required authorization letter.
3. Move to Part II and fill in the Account Holder Information. Enter the legal business name, street address, city, state and zip code, and tax identification number. Also include the 10-digit National Provider Identifier (NPI) number.
4. Continue in Part III by providing Financial Institution Information. List the name of your bank, its street address, and routing number. You will also need to include your account number and verify the account type.
5. In Part IV, fill in the Contact Person's details. This includes their name, title, telephone number, and email address, ensuring that this individual can handle inquiries concerning the form submissions.
6. In Part V, sign and date the form as the authorized or delegated official. Ensure that the signature corresponds with the official listed on the previous Medicare enrollment application.
7. Once all sections are completed, you may save your changes, download, print, or share the form as required. Make sure to submit the form as directed, either via PECOS or by mailing it to your Medicare contractor.

Complete your documents online today for a smooth authorization process.