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Click ‘Get Form’ to open the Vermont Medicaid EFT Form 2010 in the editor.
In Part I, select the reason for submission by checking either 'New EFT Authorization' or 'Revision to Current Authorization'. If applicable, attach a letter authorizing EFT payment to the Chain Home Office.
Proceed to Part II and enter your Provider/Supplier Information. Fill in your legal business name, address, Tax Identification Number, Medicare Identification Number, and National Provider Identifier (NPI). Ensure all details match IRS records.
In Part III, provide Financial Institution Information. Enter the bank's name, address, telephone number, routing transit number, and account number. Select whether it’s a checking or savings account.
Complete Part IV by entering the Contact Person’s details including their name, title, phone number, and email address.
Finally, in Part V, authorize the agreement by signing and dating the form. Ensure that you use black or blue ink for your signature.

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