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How to use or fill out EFT Enrollment Form - Blue Cross Blue Shield of Arizona with our platform

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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
2023	4.2 Satisfied (49 Votes)
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2020	4.8 Satisfied (101 Votes)
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2019	4.8 Satisfied (142 Votes)
2019	4.5 Satisfied (54 Votes)
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2019	4.8 Satisfied (54 Votes)
2019	4.8 Satisfied (79 Votes)

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