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Electronic Funds Transfer Authorization Form
To request EFT of New York Medicaid funds, complete all sections of the form below. Questions about completing this form should be directed to eMedNY Call
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Wells Fargo One Card Program
Please complete the Reason for Request for the Wells Fargo One Card Program on the application. Forms received without this information will be returned.
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Custody Agreement with Wells Fargo, N.A.
You agree to notify us promptly in writing of any change in your name, address, employment, or designation of Settlement Choice. You expressly authorize
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