PROVIDER OR SUPPLIER INFORMATION. Line 1: Enter the provider’s/supplier’s legal business name or the name of the physician or individual practitioner, as reported to the Internal Revenue Service (IRS). The account to which EFT payments are made must exclusively bear the name of the physician or individual practitioner, or the legal business name of the person or entity enrolled with Medicare. Line 2: Enter the chain organization’s name or the home office legal business name if different from the chain organization name. Line 3: Enter the account holder’s street address. Line 4: Enter the account holder’s city, state, and zip code. Line 5: Enter the tax identification number as reported to the IRS. If the business is a corporation, provide the Federal employer identification number, otherwise provide your Social Security Number.
PROVIDER OR SUPPLIER INFORMATION. Provider/Supplier Legal Business Name Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name) Account Holder’s Street Address Account Holder’s City, State, and Zip Code Tax Identification Number (designate SSN or EIN) Medicare Identification Number (if issued) National Provider Identifier (NPI) PART III: CLEARINGHOUSE USED Do you submit claims electronically? Yes No If yes, which electronic clearinghouse are you using to submit your electronic claims? Post and Track Emdeon Other:
PROVIDER OR SUPPLIER INFORMATION. Provider/Supplier Legal Business Name Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name) Account Holder’s Street Address Account Holder’s City Account Xxxxxx’s State Account Holder’s Zip Code Tax Identification Number: (designate SSN or EIN) Medicare Identification Number (if issued) National Provider Identifier (NPI) PART III: FINANCIAL INSTITUTION INFORMATION Financial Institution Name Financial Institution Telephone Number Financial Institution Contact Person Financial Institution Routing Transit Number (nine digit) Depositor Account Number Type of Account (check one) Checking Account Savings Account Please include a confirmation of account information on bank letterhead or a voided check. When submitting the documentation, it should contain the name on the account, electronic routing transit number, account number and type. If submitting bank letterhead, the bank officer’s name and signature is also required. This information will be used to verify your account number.
PROVIDER OR SUPPLIER INFORMATION. Provider/Supplier Legal Business Name Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name) Account Holder’s Street Address Account Holder’s City, State, and Zip Code Tax Identification Number (designate SSN or EIN) Medicare Identification Number (if issued) National Provider Identifier (NPI)
