New Jersey
Statewide
Medicaid Management Information System
Last updated: 5/14/2024
Authorization Agreement For Automatic Payments And Deposits
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Description
AUTHORIZATION AGREEMENT FOR AUTOMATIC PAYMENTS/DEPOSITS. This form is used to authorize Gainwell Technologies, acting as Fiscal Agent for the State of New Jersey, to deposit Medicaid payments directly into a specified checking account. It requires details about the bank account, provider information, and signatures. Providers must attach a voided check for accuracy and mail the completed form to Gainwell Technologies. www.FormsWorkflow.com
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