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Click ‘Get Form’ to open the esi eft form in the editor.
Begin by filling out the 'Authorization' section. Here, you will authorize Express Scripts Inc. (ESI) to release your electronic remittance files. Ensure that you understand the confidentiality of the information being shared.
If applicable, complete the 'Third Party Reconciler Information' section. Provide details such as Vendor Name, Contact Person, Title/Position, Address, Telephone Number, Fax Number, and E-Mail. If you are receiving files directly, leave this section blank.
Next, move to the 'Provider Information' section. Indicate whether you are an NCPDP/NPI or NCPDP/Chain provider and fill in your Provider Name, Contact Person and Title/Position, Authorized Name, and Authorized Signature along with the Date Signed.
Finally, provide your mailing address in the 'Provider Address' field along with your telephone number and e-mail address.
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Electronic Funds Transfer (EFT) The process used to transmit health care payments from a health plan to a health care providers bank is commonly called EFT.
What is EFT forms?
What is an EFT? Electronic funds transfers (EFTs) are transactions that move funds electronically between different financial institutions, bank accounts, or individuals. EFTs are frequently referred to as electronic bank transfers, e-checks, or electronic payments.
What is an EFT document?
An electronic funds transfer (EFT), or direct deposit, is a digital money movement from one bank account to another. These transfers take place independently from bank employees.
What is EFT enrollment form?
Use this form to enroll in Direct Deposit of your federal payment from the General Services Administration.
What is an EFT enrollment form?
To change your current EFT information, please complete an Electronic Funds Transfer (EFT) Authorization Agreement Form (CMS-588). Under section 1, check the box for change to current EFT enrollment.
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Download and complete the Additional Information about Your Access to Employer Sponsored Health Insurance (ESI) coverage form. EFT Form (English, PDF 166.97
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