Electronic Funds Transfer Form PDF Details

The Electronic Funds Transfer Authorization Form is a comprehensive document designed to facilitate the efficient and secure transfer of New York Medicaid funds directly into the bank accounts of healthcare providers and group practices. This form, coded EMEDNY-701101 as of March 2014, serves as a pivotal tool in the modernization of financial transactions within the healthcare sector, ensuring a streamlined process for the remittance of Medicaid payments. Its meticulous structure requires providers to furnish essential information across several sections, including provider information, provider identifiers, financial institution details, and specific submission instructions tailored to either new or changing enrollment scenarios. A notable feature of the form is the prerequisite to attach a voided check or a bank letter, reinforcing the emphasis on authenticating the accuracy of the banking details provided. Providers are advised to approach the completion of this form with precision, given its critical role in influencing the timeliness and accuracy of their Medicaid payments. Furthermore, the form underscores the significance of a clear communication channel between healthcare providers and the eMedNY Call Center, as evidenced by the detailed instructions and support offered throughout the document. In essence, the Electronic Funds Transfer Authorization Form embodies a crucial nexus between healthcare provision and financial management, ensuring that the delivery of medical services is supported by an efficient and reliable payment system.

Form NameElectronic Funds Transfer Form
Form Length5 pages
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesemedny 701101 form, emedny 436701 01 19, emedny 436701 instructions, emedny forms 701101

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To request EFT of New York Medicaid funds, complete all sections of the form below.

Questions about completing this form should be directed to eMedNY Call Center at 1-800-343-9000.

Providers will be sent a letter indicating when the new remittance advice option will begin.

EMEDNY-701101 (03/14)

Page 1 of 5




Provider Name

Provider Address


City ____________________________ State/Province ________ ZIP Code/Postal Code __________________


Provider Identifiers

Provider Federal Tax Identification Number (TIN) or Employer Identification Number: TIN EIN ___________________

National Provider Identifier (NPI) (Required, unless exempt): ____________________

Other Identifiers – Assigning Authority – New York Medicaid

Trading Partner ID: MMIS Provider ID # (Required, if NPI exempt): ___________________


Provider Contact Name

__ Telephone Number________________ Extension____











Email Address


_______ Fax Number_______________










Financial Institution Name

Financial Institution Address


City ____________________________ State/Province ________ ZIP Code/Postal Code __________________



Financial Institution Routing Number









Type of Account at Financial Institution (Check one)







Provider's Account Number with Financial Institution








Account Number Linkage to Provider Identifier






Provider Tax Identification Number (TIN) OR National Provider Identifier (NPI)

































Reason for Submission

New Enrollment


Change Enrollment










Include with Enrollment Submission

Original Voided Check


Original Bank Letter

Authorized Signature: If submitting the form for a practitioner, the practitioner must sign below.

If submitting this form for a group, business or institution, the authorized representative must sign below.



Written Signature of Person Submitting Enrollment

Submission Date



Printed Name of Person Submitting

Printed Title of Person Submitting Enrollment

CSC as the eMedNY Fiscal Agent contractor for the New York State Department of Health will have the right to recover any amount that has been credited to your account incorrectly.


Date Received:


Pick Up Indicator: No:

Yes: Facility Location:



Processed by:



















Authorized by:

















Effective Start Date:



Cycle #:













EMEDNY-701101 (03/14)





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1.To successfully authorize the use of Electronic Funds Transfer for the depositing of New York Medicaid funds, providers and group practices must perform all steps listed below.

**All Sections of the EFT form must be complete and legible; otherwise the request will not be processed and returned to the provider. **

Provider Information

Step 1. Enter the providers’/organizations’ name and address exactly as it was filed with Medicaid. This is the address as it appears on your current checks and remittance statements, if any. If you are unsure of the name and address on file with Medicaid, contact the eMedNY Call Center at 1-800-343-9000.

Provider Identifiers Information

Step 2. Enter the providers’/organizations’ Social Security Number or Tax ID supplied to Medicaid at the time of enrollment. For established providers/organizations, the Tax ID can be found on the 1099 tax form.

Step 3. Complete one of the following based on your provider type.

For Individual Providers: Enter the MMIS Provider ID or NPI in the applicable section. Enter only one provider number per application form.

For Multiple Providers: Providers with multiple provider numbers (Medicaid number or NPI) must submit a signed attachment on original letter head listing all MMIS ID’s and NPIs to be placed on EFT.

For Group Practices: Enter the group NPI if payment is made to a group practice. Enter only one provider number per application form. Provider Groups that receive payments under the Group number need only complete a single enrollment form for the Group NPI. However, members of Provider Groups who also bill individually may enroll by submitting a separate enrollment form using their individual Provider number.

Provider Contact Information

Step 4. Provide a contact name, telephone number, and email (if available) should additional information be required.

Financial Institution Information

Step 5. Enter the name and address of the banking institution to which funds are to be transferred.

Step 6. Enter the routing number and account number for the checking or savings account to which funds are to be

transferred. Both numbers can be found at the bottom of your check or letter from a banking officer.

Submission Information

Step 7. Be sure to include the required documents. Check the appropriate box for the document included with this form.

Step 8. Indicate if this is a new or change in EFT enrollment.

a.For providers already enrolled in Medicaid, check CHANGE IN ENROLLMENT. Please see page 5 for further instructions on changing banking information.

b.Enrolling providers must choose NEW ENROLLMENT.

Step 9. The form must be completed with an original signature of the provider or designated practice or business representative and date signed. Requests from individual practitioners must be signed by the practitioner. Requests from groups, business, or institutions must be signed by an authorized representative. The Title of provider or practice or business representative must be indicated.

EMEDNY-701101 (03/14)

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2.Attach one of the following banking documents to the first page of EFT Authorization Form packet:

a.For Checking Accounts: An original blank check from the checking account to which the funds are to be transferred. The word “VOID” must be written across the face of the check. The check must contain the name and address of the provider or provider organization.

b.For deposit-only checking accounts (and you do not have checks) or a savings account: Submit an original letter from a bank officer. The letter must be on bank letterhead, signed by a bank officer, notarized by a notary public, and include the following information:

1.the bank’s name and address

2.routing number

3.the type of account

4.account number

5.the account owner’s name

6.owner's address

7.owner's tax id

3.Mail the form (pages 1 and 2) and all attachments to:

Attention: EFT Processing

Computer Sciences Corporation

P.O. Box 4616

Rensselaer, NY 12144-4616

EFT Authorization Forms that do not comply with these instructions will be rejected.

Questions about form completion should be directed to the eMedNY Call Center.

Providers who have not received their EFT or Remittance Statement within 4 business days of each other should

contact the eMedNY Call Center.


In addition to the above, if the provider needs the CCD+ reassociation data elements to link the ERA to the payment, the provider must contact their financial institution, not eMedNY, to arrange for the delivery of the CORE required minimum CCD+ data elements. See Phase III CORE 370 EFT & ERA Reassociation (CCD+/835) Rule, for more details.


What to Expect

Allow a minimum of 6-8 weeks for your request to be processed. During the process period a test transaction for one cent will be transferred to your account.

For providers who have claims paid within a particular payment cycle, Medicaid funds are normally scheduled to be transferred on Wednesday afternoons. Due to normal banking procedures, the funds may not become available in the provider’s chosen account for up to 48 hours from the initial transfer. Contact your banking institution with questions about the availability of funds.

EFT does not waive the two week lag for release of Medicaid payments.

EMEDNY-701101 (03/14)

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Instructions to Change Banking Information

To change banking information, providers must send the following:

1.Complete an EFT Authorization Form with the new banking information. The form must be signed with an original signature and title must be indicated.

2.Attach a defaced/voided check with the new account number and/or routing number to the new authorization form. If the account is a "deposit only" account, attach a signed, notarized letter from your banking institution indicating the new account number and/or routing number. Regardless of what is being updated, both the account number and routing number must always be indicated.

3.Attach a letter indicating changes to your account to the new authorization form. The letter must be on company letterhead and include any provider number(s) (MMIS and NPI), new account number and/or routing number and a brief explanation for the change. The letter must have an original signature and title must be indicated.

Payments will automatically transfer back to paper for a two week time frame while your EFT is being set up on your new account.

To avoid a delay in payment please DO NOT close your old account until your new account is set up and receiving payments.

Instructions to Cancel EFT Transactions

To cancel EFT transactions:

1.Submit a written notice, including the provider number(s), applicable MMIS and/or NPIs, to the address above.

2.Verify your Pay-to Address on file is correct by calling the eMedNY Call Center at 1-800-343-9000. If the address needs to be updated, a Change of Address Form is available at www.emedny.org.

Allow 5-6 weeks to transition to a paper check.

To avoid a delay in payment please DO NOT close your account until all outstanding payments have been received.

EMEDNY-701101 (03/14)

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