Loading
Get Echo Eft And Era Enrollment Form 2019-2025
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the ECHO EFT and ERA Enrollment Form online
Filling out the ECHO EFT and ERA Enrollment Form online is a crucial step for providers seeking to streamline their payment processes. This guide will help you navigate each section of the form, ensuring that you provide all necessary information accurately and efficiently.
Follow the steps to complete the enrollment successfully.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Select your enrollment choice in the 'Form Select' section. You can choose between EFT & ERA, EFT Only, or ERA Only. Make sure to complete all sections that apply to your selection.
- Fill in the ‘Provider Information’ section, which requires the complete legal name of the provider, street address, city, state/province using the appropriate ISO code, and ZIP code/postal code.
- Provide the necessary ‘Provider Identifiers Information’, including the Federal Tax Identification Number (TIN) or Employer Identification Number (EIN). Indicate whether you have a National Provider Identifier (NPI) Number; if yes, please input it.
- If you selected EFT Only or both EFT & ERA, complete the ‘Provider Contact Information’ section with the contact name, phone number, and email address of the person who handles EFT issues.
- For users who selected ERA Only or both EFT & ERA, fill in the contact details in the ‘Provider Contact Information’ for handling ERA issues.
- If applicable, provide information about the ‘Provider Agent’ with contact details for both EFT and ERA options.
- For EFT options, complete the ‘Financial Institution Information’ section, providing the name of the financial institution, routing number, account type, and provider’s account number.
- If you selected ERA, complete the 'Electronic Remittance Advice Information' section, outlining your preference for aggregation of remittance data and method of retrieval.
- Complete the final sections, indicating the reason for submission (new, change, or cancel enrollment), print your name, submission date, and provide an authorized signature.
- Once you have filled out all necessary fields, save your changes, download the form, print it, or share it as needed.
Complete the ECHO EFT and ERA Enrollment Form online to simplify your payment processes!
Related links form
To enroll in EFT with ECHO Health, begin by downloading the ECHO EFT and ERA Enrollment Form from their platform. Fill in the form completely and return it according to the instructions provided. Completing this enrollment not only simplifies your payment process but also integrates seamlessly with ECHO's services, making your financial management much smoother.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.