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Direct Deposit/Electronic Fund Transfer (EFT) Authorization
Direct Deposit/Electronic Fund. Transfer (EFT) Authorization Form. For Reimbursement Accounts. Fax Completed Form to: 1-855-803-4887.
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Electronic-Funds-Transfer-Direct-Deposit-Authorization-Form
Please complete this form in order for us to complete your enrollment process and begin depositing your funds electronically. Alert: If you choose not to
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Electronic Funds Transfer Authorization Agreement CMS-588
PART I: REASON FOR SUBMISSION. Indicate your reason for completing this form by checking the appropriate box: New EFT enrollment or change to your EFT.
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