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How to use or fill out ePayment Enrollment Authorization Form - Providers - Select Health of South Carolina ePayment Enroll with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by completing the EFT Authorization Form. Ensure you provide an original signature and include a government-issued ID on your legal entity's letterhead.
- Fill in the contact information for your financial institution, including the name, address, and phone number. Attach a bank authorization letter or a voided check.
- On page 2, provide mandatory Provider Contact Information 1 & 2. These are essential for any inquiries regarding EFT/ERA information.
- Indicate if you wish to enroll for all TIN & NPI EFT Payers as specified on pages 5 & 6. If applicable, list individual payers starting from page 7.
- Once completed, sign and email your form as a PDF attachment to EFTEnrollment@changehealthcare.com or fax it to 615.238.9615.
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