Department Of Vermont Health Access Electronic Funds Transfer Request Form (Page 2 of 2) in pdf

Street: ______________________________________________ City: _____________________________________

State/Providence: ____________________________________ Zip Code/Postal Code: ________________________

Financial Institution Routing Number: ________________________________________

Type of Account at Financial Institution:

Checking ____

Savings ____

Providers Account Number with Financial Institution: ___________________________

Submission Information (Completion Required)

Reason for Submission:

New Enrollment ____

Change Enrollment ____

Cancel Enrollment: ____

ATTACHMENT Required for New Enrollment and Change Enrollment: Please include one of the following documents with this

form for verification of account owner and account number: (1) voided check or (2) a signed letter from your bank that lists

the account holder’s name, and the appropriate financial institution’s account and routing numbers.

I agree to keep, and disclose upon request to authorized agencies, records which disclose fully the extent of payments claimed

from and services rendered to recipients of Medicaid. I accept as payment in full the amount paid by Medicaid for claims

submitted with the exception of authorized cost sharing by recipients. I understand payment of this claim is from state and

federal funds and that any false claims, statements, documents or concealment of a material fact may be prosecuted under

state or federal law. This is to certify that the information submitted to obtain this payment is true, accurate and complete.

I authorize the electronic transfer of Vermont Medicaid payments made to the above provider number. I understand that I am

responsible for the validity of the above information.

NOTE: This EFT will not take effect until we are able to TEST with the bank to verify the accuracy of the information provided. A

MOCK DEPOSIT WILL BE EXECUTED ONLY IF YOU BILL US. After a successful $0 deposit, we will start depositing money into the

financial institutions account number specified above.

Authorized Signature: ________________________________________ Date: ______________

Printed Name of Person Submitting: ___________________________________________

__________________

If this is a new account, please indicate the earliest date for EFT processing:

Return by Fax to 802-878-3440 or mail to:

HP Enterprise Services, PO Box 888, Williston, VT 05495. Please direct all questions and EFT status

requests to the HPES Enrollment Unit at 802-879-4450 (option 4).

******************************HPES USE ONLY******************************

EFT STATUS

DATE SUBMITTED

DATE VERIFIED

TEST DATES

Rev 4-14-2015

Department Of Vermont Health Access Electronic Funds Transfer Request Form Page 2