Account Number Linkage to Provider Identifier. A 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited. The type of account the provider will use to receive EFT payments, e.g., Checking, Saving (check the appropriate box). Provider’s account number at the financial institution to which EFT payments are to be deposited (up to 10 digits). Check yes or no. If no, please provide the country of location of the account. Check one: Provider Tax Identification Number (TIN), or National Provider Identifier (NPI).
Account Number Linkage to Provider Identifier. Provider Tax Identification Number (TIN) National Provider Identifier (NPI) Provider preference for grouping (bulking) claim payments – must match preference for v5010 X12 835 remittance advice Enter the provider’s preference for grouping claim payments – either by TIN or NPI. Please note that the account number entered here must match the Preference for Aggregation of Remittance Advice Data to be entered at the time a Trading Partner or provider enrolls for an Electronic Remittance Advice.
Account Number Linkage to Provider Identifier. Provider Tax Identification Number (TIN) National Provider Identifier (NPI) SUBMISSION INFORMATION (Data Element Group 8) *Reason for Submission New Enrollment Change Enrollment Cancel Enrollment Include with Enrollment Submission Voided Check Bank Letter *Authorized Signature Electronic Signature of Person Submitting Enrollment Written Signature of Person Submitting Enrollment Printed Name of Person Submitting Enrollment Printed Title of Person Submitting Enrollment Submission Date (CCYYMMDD) Requested EFT Start/Change/Cancel Date (CCYYMMDD) AUTHORIZATION FOR SETUP I hereby authorize the State of Utah ("the State") to initiate credit entries to the account number listed above ("this account"). I further authorize the State to correct credit entries made in error to this account. I agree that this AUTHORIZATION FOR SETUP is to remain in full force and effect until the State has received written notification from me of its termination, in such time and manner as to afford the State and the Financial Institution a reasonable opportunity to act upon my notification. I recognize that if I fail to provide complete or accurate information on the above DIRECT DEPOSIT AUTHORIZATION FORM FOR ELECTRONIC FUNDS TRANSFERS (EFT) FOR MEDICAID PROVIDERS ("this form"), the processing of this form may be delayed and/or my payments may be erroneously transferred. In the event that funds are erroneously transferred due to my failure to provide complete or accurate information on this form, I hereby hold the State harmless for the recovery of such erroneous transfers, not withstanding any reasonable attempts made by the State to correct such errors. I understand that payment will be from Federal and State funds and that any falsification or concealment of a material fact, may be prosecuted under Federal and State laws. I, the undersigned certify that I am authorized to provide the above information and the information is true and correct.
Account Number Linkage to Provider Identifier. Provider Tax Identification Number (TIN) OR National Provider Identifier (NPI) Method of Retrieval Trading Partner Secure Web Portal Safe Harbor Connectivity Submission Information: Reason for Submission New Enrollment Change Enrollment Cancel Enrollment I authorize the electronic remittance advice enrollment under the Connecticut Medical Assistance Program. I understand that I am responsible for the validity of the above information. Authorized Signature Requested ERA Effective Date: Return this form to: DXC Services LLC X.X. Xxx 0000 Xxxxxxxx, XX 00000 Note: Paper Trading Partner Agreement forms will not be accepted after July 1, 2019. Trading Partners should go to xxx.xxxxxxxx.xxx to complete and on-line Trading Partner Agreement.
