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Click ‘Get Form’ to open the ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION in the editor.
In Part I, select your reason for submission: New EFT Enrollment, Change to Current EFT Enrollment, or Cancel EFT Enrollment. If applicable, attach a letter authorizing payment to the Chain Home Office.
Proceed to Part II and fill in the Account Holder Information. Enter the legal business name, address, Tax Identification Number (TIN), and Medicare Identification Number if issued.
In Part III, provide Financial Institution Information including the bank's name, address, routing number, and account number. Ensure all details are accurate for processing.
Complete Part IV by entering the Contact Person’s details who will handle inquiries regarding this form.
Finally, in Part V, authorize the agreement by signing and dating it. Ensure that you use black or blue ink for your signature before submitting.
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Participating Providers are required to enroll for Electronic Funds Transfer (EFT) and. Electronic Remittance Advice (ERA). Providers enrolled in EFT paymentsRead more
Electronic Funds Transfer (EFT) - UC Berkeley Controllers Office
The primary purpose for requesting information on this form is to acquire authorization to disburse payments directly to a financial institution of your choice.Read more
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