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EFT ERA Authorization Agreement Instructions - Optima Health 2026
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- Click ‘Get Form’ to open the EFT ERA Authorization Agreement in the editor.
- Begin by filling out the 'Payer / Insurance Company Name' section. Specify only one payer per form.
- Provide your ECHO Draft Number and Draft Amount if applicable, especially for EFT enrollments.
- Complete the 'Provider Information' section with your legal name, address, and contact details.
- In the 'Provider Identifiers Information' section, enter your TIN or EIN and indicate if you have an NPI number.
- Fill out the 'Financial Institution Information' with your bank's name, routing number, and account details for EFT payments.
- For Electronic Remittance Advice (ERA) preferences, specify how you wish to receive remittance data and provide any necessary clearinghouse information.
- Finally, complete the submission information including reason for submission and authorized signature before sending it to ECHO Health.
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Outdated Form. Circular Letter No: 100-166-97-attach 2. The Electronic Fund Transfer (EFT) Authorization. Agreement form in this Circular Letter is outdated.