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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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electronic funds transfer authorization form - eMedNY
ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM. EMEDNY-701101 (11/16) To request EFT of New York Medicaid funds, complete all sections of the form below.
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Electronic Funds Transfer (EFT) Payment Enrollment Form
This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment related information.
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