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How to Use or Fill Out the EFT Authorization Agreement Form
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- Click ‘Get Form’ to open the EFT Authorization Agreement in our editor.
- In Part I, select your reason for submission by checking the appropriate box: New EFT Enrollment, Change to Current EFT Enrollment, or Cancel EFT Enrollment. If applicable, attach a letter authorizing payment to the Chain Home Office.
- Proceed to Part II and fill in the Account Holder Information. Enter the legal business name, practice location address, Tax Identification Number (TIN), and National Provider Identifier (NPI) as required.
- In Part III, provide details about your Financial Institution including its name, address, routing number, and account number. Ensure you specify whether it’s a Checking or Savings account.
- Complete Part IV by entering the Contact Person's information who can answer questions regarding this form.
- Finally, in Part V, authorize the agreement by signing and dating the form. Make sure to include your contact details for any follow-up.
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