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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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