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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