Electronic Claims Payment For Providers 2025

1. Click ‘Get Form’ to open the Electronic Claims Payment For Providers in the editor.
2. Begin with Part I: Reason for Submission. Select one option that applies: New EFT Authorization, Cancel EFT, Revision to Existing Enrollment, or Enroll in Electronic Remittance Advice (ERA).
3. In Part II: Pharmacy/Organization Information, fill in your Tax ID, Chain Code/Payment Center ID/NCPDP, Organization Name, Address, City, State, and Zip Code.
4. Proceed to Part III: Pharmacy/Organization Contact. Enter the contact person's Name, Title, Email Address, Phone Number, and Fax Number.
5. For Part IV: Designation of Depository, provide Bank Name, Account Name, Bank Address details including City, State, Zip Code. Also include Bank Contact Name and Phone Number along with Bank Account Number and Routing Transit Number.
6. Select the Account Type as either Checking or Savings Account. Remember to attach a voided check as instructed.
7. In Part V: Electronic Remittance Advice Information, fill out the contact information if you wish to receive electronic remittance. Choose your preferred ERA Delivery Option.
8. Complete the Authorization section by providing your Printed Name, Signature, Title and Date.
9. Finally, return the completed form via fax or email as specified at the end of the document.

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