Department Of Vermont Health Access Electronic Funds Transfer Request Form printable pdf download

Department of Vermont Health Access Electronic Funds Transfer Request Form

Provider Information (Completion Required)

CLARIFICATION: A Taxpayer Identification Number (TIN) is an identification number used by the Internal Revenue Service (IRS) in

the administration of tax laws. It is issued either by the Social Security Administration (SSA) or by the IRS. A Social Security

number (SSN) is issued by the SSA whereas all other TINs are issued by the IRS. An atypical provider not eligible for enumeration

by an NPI must supply its EIN/TIN.

Provider Name: ____________________________________________________________

Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): ___________________________

National Provider Identifier (NPI) (If applicable): __________________________________

Assigning Authority (VT Medicaid Provider Number): ______________________________

Provider Taxonomy Code: ____________________________________________________

Provider Contact Information (Name of a contact in provider office for handling EFT issues – Completion Required)

Provider Contact Name: ________________________________ Telephone Number: _________________________

E-mail Address: _______________________________________

Billing Agent Information (Completion of this section is optional and does not apply to all providers)

The following section must be completed if the EFT for the provider named on this document will be sent to a bank account

belonging to a billing agent and not the bank account of the provider.

The exception for a business agent is limited to agents who furnish statements and receive payments in the name of the

provider, and the service provided by the agent is: (1) related to the cost of processing the bill; (2) not related to a percentage

or other basis to the amount billed or collected; and (3) not dependent upon the collection of payment. Further, a payment for

a provider may not be made to or through an individual or organization (collection agency or service bureau), or by power of

attorney thereof, that advances money for accounts receivable a provider has assigned, sold, or transferred to the individual or

organization for a fee or deduction of accounts receivable.

Does This Account Belong to a Billing Agency or Group?

Yes ____

No ____

If Yes, please complete below section. If No, completion is not required.

Provider Agent Name (Name of providers authorized agent): __________________________________________________

Street: ______________________________________________ City: ________________________________________

State/Providence: _____________________________________ Zip Code/Postal Code: __________________________

Provider Agent Contact Name: ___________________________________ Telephone Number: ____________________

E-mail Address: ______________________________________________

Financial Institution Information (Completion Required)

Financial Institution Name: __________________________________________

Rev 4-14-2015

Department Of Vermont Health Access Electronic Funds Transfer Request Form