Healthfirst Eft Era Authorization Form PDF Details

The Healthfirst Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Authorization form is a crucial document for healthcare providers who wish to streamline their financial transactions with Healthfirst. Revised on November 17, 2006, this form allows for several types of transactions, including the addition or change of ERA and EFT settings, and the termination of these services. To ensure a smooth and unified process, it's required that only one form is filled out per tax ID, given that all providers within a group utilize the same banking account. Along with this form, it's necessary to attach a list of provider IDs to signify whose authorizations are being requested. Providers can choose between bank account types for EFT such as checking, savings, demand deposit, or money market accounts. Additionally, for ERA participation, the form inquires about the clearinghouse used by the provider or their vendor, emphasizing the necessity to use one of the listed clearinghouses to avail of ERA services. This authorization remains active until Healthfirst receives a written termination notice providing sufficient time for proper processing. It's highlighted that any ERA and EFT transactions will abide by Healthfirst's policies, which may be subject to change, and can be discontinued anytime. Providers preferring only ERA services must note this specifically, keeping in mind that paper remittances become unavailable after a grace period. The form also requests contact information for follow-ups and directs where to submit completed forms, providing multiple submission options including mail, email, and fax, ensuring accessible support for providers.

QuestionAnswer
Form NameHealthfirst Eft Era Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesEmdeon, healthfirst eft authorization form, healthfirst eft era authorization form, remits

Form Preview Example

EFT/ERA Authorization Form

Rev. 11/17/06

Type of Transaction (please choose)

Add ERA and EFT

Change ERA

Terminate ERA and EFT

 

Change EFT

 

Provider/Physician Name (please print)

Physician Group Notes:

•You need only fill out one EFT/ERA Authorization form per Tax ID

as long as all the providers in the group have the same bank account.

•Please attach a list of the provider IDs, at the payee entity level, for whom you wish the Authorization to apply

Healthfirst Provider ID Number NATIONAL PROVIDER IDENTIFIER (NPI)

Federal Employer Identification Number

 

 

 

Provider Type (please choose one)

 

Ancillary

Hospital

Physician

Physician Group

 

 

 

 

 

 

I hereby authorize Healthfirst, hereafter called COMPANY, to initiate credit entries and if necessary, adjustments for any credit entries to one of the following accounts indicated below and the depository named below, hereafter called DEPOSITORY, to credit the same to such account.

Account Type (please choose one if you wish to participate in the EFT process)

Checking Savings Demand Deposit Money Market

Account Name _____________________________________________________________________________________

Depository/Bank Name (please print)

 

 

Address (please print)

 

 

 

 

 

City

State

Zip

 

Phone

 

 

 

 

Please include a deposit slip/cancelled

 

 

 

 

check if you wish to participate in EFT.

Routing Number

Account Number

 

 

 

If you wish to participate in our ERA process, please identify which Clearing House you (or your vendor) are currently using. Please note that you or your vendor must use one of the clearing houses in order to participate in our ERA process.

Emdeon I-UB92

Emdeon P-HCFA 1500

Other: Name_______________

This authority is to remain in full force and effect until COMPANY has received written notification from me of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on said notice of termination. Provider agrees that all ERA and/or EFT transactions will be conducted in accordance with company’s policies and procedures (and may be changed from time to time) and may be suspended or discontinued at any time.

Special ERA/Paper Remittance Note

I wish to receive ERA only.

Please note: At the conclusion of the grace period, paper remits will no longer be available.

Name (please print)

Title

 

 

Signature

Date

Please provide the name of a contact person that can verify and provide any changes in the above listed data.

Contact Name (please print)

Title

Phone Number

Email Address

 

 

 

 

Address

City

State

Zip

Please direct all questions to:

Completed forms can be submitted as follows:

Phone: 888-801-1660

Mail: Provider Services, P.O. Box 5168, New York, NY 10274-5168

 

E-Mail:. ERAEFT confirmation@healthfirst.org or Fax: 646-313-4635

www.healthfirstny.com

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Step # 1 in completing healthfirst eft authorization form

2. Once your current task is complete, take the next step – fill out all of these fields - DepositoryBank Name please print, Address please print, City, State, Zip, Phone, Routing Number, Account Number, Please include a deposit, If you wish to participate in our, Emdeon IUB Emdeon PHCFA Other, Special ERAPaper Remittance Note m, This authority is to remain in, Name please print, and Signature with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

healthfirst eft authorization form completion process clarified (part 2)

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