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EFT Electronic Fund Transfer Authorization - California
| EFT Electronic Fund Transfer Authorization Form. This is a California form and can be used in Medi Cal Statewide . |
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EFT ELECTRONIC FUND TRANSFER AUTHORIZATION DEPARTMENT OF HEALTH CARE SERVICES MEDI-CAL: This authorization remains in full force and effect until the California Medicaid Program/Title XIX receives written notification from the provider of its termination, or until the California Medicaid Program/Title XIX or appointing authority deems it necessary to terminate the agreement. DIRECTIONS: An original pre-imprinted voided check for checking accounts, or an original bank letter for savings accounts, must be submitted with this form. The provider name, routing number and account number on either of those documents must match what is entered on this form. Photocopied documents will not be accepted. Use blue ink for signatures, including notary. SECTION A 1. NAME OF PROVIDER (must match name on bank account and name registered with Medi-Cal) PLEASE PRINT OR TYPE 2. NPI OR LEGACY NUMBER (one EFT form per number) 3. NAME OF MAIN CONTACT PERSON 4. TELEPHONE NUMBER 5. PROVIDER ADDRESS CITY STATE ZIP 6. LAST 4 DIGITS OF PROVIDER SOCIAL SECURITY NUMBER OR COMPLETE FEDERAL TAX ID NUMBER (must match number registered with Medi-Cal) SECTION B 1. BANK ROUTING NUMBER 2. BANK ACCOUNT NUMBER (include leading zeros) 3. TYPE OF ACCT CHECKING SAVINGS 4. BANK NAME 5. BANK ADDRESS CITY STATE ZIP SECTION C (Check the appropriate box) I hereby authorize the California Medicaid Program/Title XIX to initiate credit entries to my bank account as indicated above, and the depository named above to credit the same to such account. For changes to existing accounts, do not close an existing account until the first payment has been deposited into the new account. I hereby CANCEL my EFT authorization. I understand that by signing this form, payments issued 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. Provider Signature (BLUE INK ONLY. Must be owner or corporate officer.) Date FORM MUST BE NOTARIZED MAIL THIS FORM TO: EXPRESS MAIL ONLY: ACS Attn: EFT Unit 820 Stillwater Road West Sacramento, CA 95605 ACS Attn: EFT Unit PO Box 13029 Sacramento, CA 95813-4029 Privacy Statement (Civil Code Section 1798 et seq.): The information requested on this form is required by the Department of Health Care Services for purposes of identification and document processing. Furnishing the information requested on this form is mandatory. Failure to provide the mandatory information may result in your request being delayed or not processed. 1 Electronic Fund Transfer PROPubs 10/11 American LegalNet, Inc. www.FormsWorkFlow.com
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