Essence HealthCare EFT Authorization Agreement

Electronic Funds Transfer (EFT)

Authorization Agreement

Electronic Funds Transfer (EFT) is a free and secure way for you to receive your payments faster. You will no longer have

to wait for checks to arrive in the mail. Essence Healthcare can issue EFTs to all healthcare provider types, including those

receiving capitation. Enrollment in the EFT program does not change our overpayment process. If we determine an

overpayment has been issued, we will send you a letter requesting a refund by check.

Use the following as a guide when completing the EFT agreement. *Fields with an asterisk are required; sections left

blank or illegible will delay processing. The following is a reference guide only; do not fax with the completed agreement.

1. PROVIDER INFORMATION

Provider Name: Enter the complete legal name of the individual provider, practice, institution, or corporate entity.

Doing Business as Name (DBA): The name under which the business is operated. This may or may not be the same

as the legal name above.

Provider Address: The number and street name where a person or organization can be found.

2. PROVIDER IDENTIFIER INFORMATION

Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) or Social Security

Number (SSN): Enter the tax identification number as reported to the IRS. If the business is a corporation, provide the

Federal employer identification number, otherwise provide your Social Security Number.

National Provider Identifier (NPI): Enter the 10 digit Group NPI number of the payee. The NPI is the unique 10-digit

identification number issued to health care providers by the Centers for Medicare and Medicaid Services. This is a

required field.

3. PROVIDER CONTACT INFORMATION

Provider Contact Name, Phone Number and Email: Enter the name, phone number and email address of the

contact person regarding EFTs.

4. PROVIDER AGENT INFORMATION (NOT APPLICABLE)

5. FEDERAL AGENCY INFORMATION (NOT APPLICABLE)

6. RETAIL PHARMACY INFORMATION (NOT APPLICABLE)

7. FINANCIAL INSTITUTION INFORMATION

Financial Institution Name: Enter the official name of the payee’s financial institution.

Financial Institution Address: Enter the financial institution’s street address, city, state and ZIP code.

Financial Institution Routing Number: Enter the bank or financial institutional nine-digit routing number.

Type of Account at Financial Institution: Note whether this account is a checking or savings account. Provider’s

Account Number with Financial Institution: Enter the payee’s account number with the financial institution.

Account Number Linkage to Provider Identifier: Account number linkage to provider identifier; either TIN or NPI.

A voided check or bank letter is required to be submitted with this form; deposit slips will not be accepted. If you do not

submit a voided check or bank letter, the form will be considered incomplete and will be returned to you.

8. SUBMISSION INFORMATION

Reason for Submission: Check one of the options for the reason for submission from the available options.

Include with Enrollment Submission: Please indicate which item is being submitted as proof of account.

Authorized Signature – The signature of an individual authorized by the provider to initiate, modify or terminate an

EFT Authorization Agreement.

Submission Date: The date on which the EFT agreement form is submitted.

Essence HealthCare EFT Authorization Agreement

Electronic Funds Transfer (EFT)

Authorization Agreement

Please note:

Fax only one form per Taxpayer Identification Number/National Provider Identifier (TIN/NPI) combination.

Illegible or incomplete fields may cause your enrollment to be delayed.

“*” Indicates required fields within each section. Incomplete and/or illegible fields and signatures may cause your

enrollment to be delayed. Please ensure this form reflects the banking and TIN/NPI information related to the

provider record under which you currently receive payment.

2. Provider Identifiers Information

*Provider Federal Tax Identification Number (TIN) Or

Employer Identification Number (EIN):

*National Provider Identifier (NPI):

3. Provider Contact Information

*Provider Contact Name: *Provider Contact Phone:

*Provider Contact Email:

4. Provider Agent Information (Not Applicable)

5. Federal Agency Information (Not Applicable)

6. Retail Pharmacy Information (Not Applicable)

7. Financial Institution Information

You MUST include a voided check or bank letter in order to enroll in EFT.

Deposit Slips will NOT be accepted.

Direct Deposits will be applied to a single account only, split payment amounts are not allowed.

To take advantage of Direct Deposit (EFT), your financial institution must be a participating member of the Automated

Clearinghouse Association (ACH). Please allow 30 days from the submission date to process any new EFT enrollments or

modifications to existing financial information. You are responsible for notifying Essence Healthcare if any of the above

information changes. Essence Healthcare will continue issuing payment in accordance with this agreement until proper

notification is received.

*Financial Institution Name: *Type of Account at Financial Institution:

Checking ☐ Savings ☐

*Financial Institution Address: *City: *State: *Zip:

1. Provider Information

*Provider Name: Doing Business As Name (DBA):

*Provider Address: *City: *State: *Zip:

Essence HealthCare EFT Authorization Agreement

*Financial Institution Routing Number:

(9 digits found on check, NOT deposit slip)

*Provider's Account Number with Financial Institution:

(voided check or bank letter required, deposit slips will not be accepted)

*Account Number Linkage to Provider Identifier: (select one of the two below)

☐ Provider Tax Identification Number (TIN) or Employer Identification Number (EIN) or Social Security Number (SSN)

☐ National Provider Identifier (NPI)

8. Submission Information

*Reason for Submission: (select from below)

☐ New Enrollment

☐ Change Enrollment

☐ Cancel Enrollment

*Include with Enrollment Submission: (select from below)

☐Voided Check

☐Bank Letter

By signing this form you certify the account named above is drawn in the name of the physician, individual practitioner or

in the legal business name of the Provider. The Provider has sole control of the account to which EFT deposits are made in

accordance with all applicable regulations and instructions. Arrangements between the financial institution and the

provider are in accordance with applicable regulations and instructions with the effective date of the EFT authorization.

You must notify Essence Healthcare regarding any changes to the above information to allow Essence Healthcare and the

financial institution to implement the changes. The EFT authorization form must be signed and dated by the same

Authorized Representative as the original request.

*Authorized Signature: *Submission Date:

Please note: Incomplete and/or illegible signatures will cause your enrollment to be delayed.

Send completed form, voided check and/or bank letter to Essence Healthcare via fax or email:

Fax: 314-770-6034

Please submit only one form per FAX. Faxes containing multiple forms will be returned.

Email: providereft@essencehealthcare.com

If you need assistance completing this form or would like to check on status of an EFT request, please contact Essence

Healthcare Customer Service at 314-209-2700 or 866-597-9560, Option 5, Option 2.