Electronic Funds Transfer Enrollment Form

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Electronic Funds Transfer Enrollment Form
FAX
Please
All Forms to:
Electronic Funds Transfer (EFT) Support
(404) 682-3238
Atlanta, North Georgia and South Georgia - Please contact your local Representative.
OR
Mail Forms to:
Blue Cross Blue Shield of Georgia
Electronic Remittance Advice (ERA) Support
3350 Peachtree Road
EDI Services / GA014-0007
(888) 883-2720 (ERA only)
Atlanta, Ga 30326
Complete this form to request scheduling for implementation of EFT for the provider / faciilty indicated below.
NOTE: A separate form is required for each Tax Identification Number & Location
.
.
Incomplete enrollment form will cause delay
Provider Name: __________________________________________________________________________________
Provider/Supplier Legal Business Name:_______________________________________________________________
Tax ID Number: ________________________________________ Location Suffix:_ _ _
(
New form required for each suffix,
See Instruction page)
Physical Address: _______________________________________ Suite: ____________________________________
City: ____________________________ State:_____
ZIP Code:__________________
Phone:____________________
Fax:___________________
Contact Name: ______________________________
Direct Deposit Authorization
Blue Cross Blue Shield of Georgia Systems is hereby authorized to deposit payments for claims to the account listed below.
PLEASE ATTACH A COPY OF A "VOIDED CHECK" FOR THE BANK ACCOUNT TO RECEIVE DIRECT DEPOSIT.
PROVIDER / FACILITY NAME NAME:
SUFFIX:
TAX ID NUMBER:
ADMINISTRATIVE CONTACT:
PHONE NUMBER:
TITLE:
BANK INFORMATION
NAME ON BANK ACCOUNT
ACCOUNT TYPE
Checking
Savings
BRANCH NAME:
BANK NAME:
BANK ADDRESS :
BANK PHONE NUMBER:
ACCOUNT NUMBER:
TRANSIT/ABA NUMBER:
An authorized signer on the bank account must sign this form
* =Required
*
Authorized/Delegated Official Name (print):
Authorized/Delegated Official Title (print):
*
Authorized/Delegated Official Signature:
*
* DATE SIGNED:
Blue Cross Blue Shield of Georgia is an Independent Licensee of the Blue Cross Association. Blue Cross and the Blue Cross symbol are Registered Marks of the Blue Cross Association.

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