Healthfirst Eft Era Authorization Form PDF Details

Are you having trouble understanding the Healthfirst Eft Era Authorization Form? If so, you aren't alone! The form can be confusing and knowing which information is needed to complete it properly can be time-consuming. We have put together this comprehensive blog post to walk you through everything there is to know about the Healthfirst Eft Era Authorization Form, so that you can quickly and easily fill out your form for an authorized payment. So don't worry - by reading this blog post, getting your authorization will soon become a breeze!

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

How to Edit Healthfirst Eft Era Authorization Form Online for Free

Emdeon can be filled out online effortlessly. Just open FormsPal PDF tool to finish the job right away. To maintain our editor on the leading edge of efficiency, we work to put into operation user-driven capabilities and enhancements on a regular basis. We are routinely looking for suggestions - join us in revampimg the way you work with PDF files. Here is what you would have to do to get started:

Step 1: First, access the pdf tool by pressing the "Get Form Button" at the top of this site.

Step 2: This editor enables you to change PDF forms in a variety of ways. Transform it by writing your own text, correct existing content, and include a signature - all within a couple of mouse clicks!

As for the fields of this precise PDF, this is what you should do:

1. Start filling out your Emdeon with a number of major blanks. Gather all of the required information and make sure nothing is left out!

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)

It is easy to get it wrong when filling out the City, for that reason make sure that you take another look before you decide to submit it.

Step 3: Go through all the information you have inserted in the form fields and then click the "Done" button. Obtain your Emdeon once you join for a 7-day free trial. Conveniently use the pdf in your FormsPal cabinet, along with any edits and changes conveniently synced! Here at FormsPal.com, we endeavor to ensure that your details are stored secure.

Healthfirst Eft Era Authorization Form isn’t the one you’re looking for?

Related Documents