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How to use or fill out EFT Enrollment Form - Blue Cross Blue Shield of Arizona with our platform
- Click ‘Get Form’ to open the EFT Enrollment Form in the editor.
- Begin by filling out the 'Provider Information' section. Enter your legal name, DBA (if applicable), and complete your address details including street, city, state, and zip code.
- Next, move to 'Provider Identifiers Information'. Input your Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) along with your National Provider Identifier (NPI).
- In the 'Provider Contact Information' section, provide a contact name, telephone number, email address, and fax number for any inquiries related to EFT.
- Proceed to 'Financial Institution Information'. Fill in the financial institution's name and address. Include the routing number and account type (checking or savings), followed by your account number.
- Complete the 'Submission Information' section by selecting whether this is a new enrollment, change enrollment, or cancellation. Don’t forget to attach a voided check or bank letter as required.
- Finally, sign and date the form electronically before submitting it via email or fax as instructed.
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| Versions | Form popularity | Fillable & printable |
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| 2023 | 4.4 Satisfied (32 Votes) | |
| 2023 | 4.2 Satisfied (49 Votes) | |
| 2022 | 4.8 Satisfied (55 Votes) | |
| 2020 | 4.8 Satisfied (247 Votes) | |
| 2020 | 4.8 Satisfied (101 Votes) | |
| 2020 | 4.4 Satisfied (134 Votes) | |
| 2020 | 4.8 Satisfied (261 Votes) | |
| 2020 | 4.8 Satisfied (117 Votes) | |
| 2020 | 4.3 Satisfied (26 Votes) | |
| 2020 | 4.7 Satisfied (51 Votes) | |
| 2020 | 4.2 Satisfied (36 Votes) | |
| 2020 | 4.1 Satisfied (59 Votes) | |
| 2020 | 4.5 Satisfied (39 Votes) | |
| 2019 | 4.8 Satisfied (130 Votes) | |
| 2019 | 4.8 Satisfied (79 Votes) |
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