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In Part I, select your reason for submission by checking the appropriate box: either 'New EFT Enrollment' or 'Change to Current EFT Enrollment'. If applicable, attach a letter authorizing payments to a chain organization.
Proceed to Part II and enter the account holder information. This includes the legal business name, street address, city, state, zip code, tax identification number (TIN), National Provider Identifier (NPI), and Medicare identification number if issued.
In Part III, provide details about your financial institution. Enter the bank's name, address, contact person’s name and phone number, routing number, and your account number. Ensure that all information matches the legal business name.
Complete Part IV by entering the contact person's details who can answer questions regarding this form.
Finally, in Part V, sign and date the form as an authorized representative. Ensure you include a contact number for any follow-up.

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