Electronic Funds Transfer Enrollment Form (Page 2 of 2) in pdf

Electronic Funds Transfer Enrollment Form Page 2

Electronic Funds Transfer

ENROLLMENT INSTRUCTIONS

1. In order to receive EFT (Electronic Fund Transfer) you must also retrieve 835 ERA (Electronic

Remittance Advice).

2. If you are not set up to retrieve 835 ERA, please contact your Clearinghouse, Billing Service or

Software Vendor to submit the necessary 835 ERA enrollment form.

3. One 835 ERA enrollment form is required for each Tax ID Number.

4. One EFT enrollment form is required for EACH location.

5. Each location has a Suffix identifier. Please refer to a recent EOB and note the TAX ID number and

the 3 digit Suffix. I.e. 58-0000000 001. If you are unable to locate your suffix(es), please contact

provider relations at 404 231 0428 and request the suffix for each location.

6. Fax completed forms to (404) 682 - 3238.

7. Incomplete forms will be returned and will delay the enrollment process.

8. Hard copy Remittance Advice shall be discontinued thirty (30) days from the date of the first 835

ERA file transfer.

9. Please do not fax this instruction sheet along with your completed EFT Enrollment form.

10. PLEASE ATTACH A COPY OF A VOIDED CHECK FOR THE BANK ACCOUNT TO RECEIVE

THE DIRECT DEPOSIT

EFT Support

Atlanta, North Georgia and South Georgia

Please contact your local Representative

ERA Support ONLY

(888) 883-2720

Electronic Funds Transfer Enrollment Form Page 2