(EFT) Enrollment Application - refugeesinpa: Fill out & sign online

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Click ‘Get Form’ to open the (EFT) Enrollment Application in the editor.
Begin by filling out the Provider Information section. Enter the complete legal name, payment address, city, state code, and zip code.
In the Provider Identifiers 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 by entering the contact name, telephone number, and email address for any EFT-related inquiries.
Next, fill in the Financial Institution Information. Include the institution's name, address, routing number, account type, and account number.
Select a reason for submission: New Enrollment, Change Enrollment, or Cancel Enrollment. Attach either a voided check or a bank letter as required.
Finally, provide authorized signatures and print names before submitting your completed form to the specified address.

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