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Electronic Fund Transfer Request

Click here for Instructional PDF.


* Required
   

Provider Information
*Provider Name
Provider Address
* Street
*City
*State/Province
*ZIP Code/Postal Code
Provider Identifiers Information
*Provider Federal Tax Identification Number (TIN) or Employer Identification Number(EIN)
National Provider Identifier NPI
Provider Contact Information
*Provider Contact Name
*Telephone Number
*Email Address
Fax Number
Financial Institution Information
*Financial Institution Name
*Routing Number
*Type of account Checking
Saving
*Provider Account Number
*Account Number Linkage to Provider Identifier(Must match ERA Preference) Provider Tax Idenfication Number(TIN)
National Provider Idenfication Number(NPI)
Provider Tax Idenfication Number(TIN)
National Provider Idenfication Number(NPI)
*Reason for submission New Enrollment
Change Enrollment
Cancel Enrollment
Include with Enrollment Submission Voided Check
Bank Letter