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Change healthcare eft 2026
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- Click ‘Get Form’ to open the Change Healthcare EFT Enrollment form in the editor.
- Begin by filling out the Provider Information section. Enter your Provider Name, Doing Business As (DBA) name, and complete the address fields including Street, City, State/Province, Zip Code/Postal Code, and Country Code.
- In the Provider Identifiers Information section, provide your Federal Tax Identification Number (TIN) or Employer Identification Number (EIN), along with your National Provider Identifier (NPI).
- Complete the Provider Contact Information sections. You will need to enter details for at least two contacts including names, titles, telephone numbers, email addresses, and fax numbers.
- Fill in the Provider Agent Information if applicable. This includes the agent's name, address, contact information, and title.
- Review the acknowledgment section carefully. By signing here, you confirm that all provided information is accurate and agree to comply with Change Healthcare’s terms.
- Finally, submit your completed form via email to EFTEnrollment@ChangeHealthcare.com or fax it to 615-238-9615.
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