Financial Institution Routing Number. A 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited Enter the 9-digit financial institution routing number where payments are to be deposited.
Financial Institution Routing Number. A 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited, including any leading zeros (see image below). Do not include any dashes or spaces. Provider’s Account Number: Provider’s account number at the financial institution to which EFT payments are to be deposited, including any leading zeros (see image below). Do not include any dashes or spaces. Provider Certification Signature of Authorized Person Submitting Form: The signature of an individual authorized by the provider or its agent to initiate, modify, or terminate an EFT enrollment. By signing the form, this person certifies that they have legal authority to make these changes. An original signature is required and must be in blue ink. Date: The date on which the EFT enrollment form is signed. Print Name: Print the name of the person signing the form. Title: Print the title of the person signing the form. Notarized By: Print the name of the Notary Public. On (Date): The date the form was notarized.
Financial Institution Routing Number. (Include 9 digits w ith any leading zeros.) To indicate account type, select one checkbox. Checking Account | Savings Account Please provide your financial institution routing number and account numbers as referenced on your deposit account or checking account (see example for reference) Authorization I hereby authorize UnitedHealthcare Services, Inc., on behalf of itself and its affiliates, (hereinafter “Company”) to initiate credit entries to the account at the financial institution listed above for all payments. I authorize and request the financial institution to accept credit entries by Company to such account and to credit the same to such account. If Company credits more money than the correct payment amount due to duplicate electronic funds transfers (where “duplicate” is defined as multiple electronic funds transfers received for the same services rendered, the same membership, and the same dates of service) or erroneous electronic funds transfers (where “erroneous” is defined as complete electronic funds transfers received in error) I authorize Company to withdraw the overpayment electronically. I accept responsibility for any resulting loss of payment and release Company from any liability for or arising from my failure to submit accurate or updated information to Company. I understand that I must communicate any changes in my information to Company. This authorization is effective as of the signature date below and is to remain in full force and effect until Company has received written notification from me of its termination or Company notifies me that this service has been terminated. I agree to provide notification of change/termination 30 days in advance. By signing this authorization, I acknowledge that I have read and agree to the conditions set forth herein. Furthermore, I certify that the information provided is true and accurate in all respects and that I have been duly authorized to enter into this agreement. Printed Name Title
Financial Institution Routing Number. Type of Account at Financial Institution Checking Savings Provider’s Account Number with Financial Institution Reason for Submission New Enrollment Change Enrollment Cancel Enrollment Include with Enrollment Submission Voided Check or Bank Letter Authorized Signature Written Signature of Person Submitting Enrollment Printed Name of Person Submitting Enrollment Submission Date Requested EFT Start/Change/Cancel Date Electronic Funds Transfer (EFT) Authorization Agreement-Continued Please forward the completed EFT form to the following: Fax Number 000-000-0000 Blue Cross Blue Shield of Kansas City 0000 Xxxx Xx., Xxxxxx Xxxx, XX 00000 Email: xxxxxxxxxxx@xxxxxx.xxx For any questions: Please contact Blue Cross Blue Shield of Kansas City at 000-000-0000 or 000-000-0000 Email: xxxxxxxxxxx@xxxxxx.xxx
