MeridianRx Electronic Funds Transfer EFT Enrollment Form 2026

1. Click ‘Get Form’ to open it 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. Proceed to 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. In Part III: Pharmacy/Organization Contact, provide the Name, Title, Email Address, Phone Number, and Fax Number of the primary contact person.
5. Move to Part IV: Designation of Depository. Enter Bank Name, Account Name, Bank Address details including City and State. Also include Bank Contact Name and Phone Number along with Routing Transit Number and Bank Account Number. Specify the Account Type as Checking or Savings.
6. If applicable, complete Part V: Electronic Remittance Advice Information by providing contact details for electronic remittance setup.
7. Finally, review the Authorization section carefully before signing. Ensure all information is accurate and complete.

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