1. Healthcare

Electronic Funds Transfer (EFT)
Authorization Agreement
Provider Information
Provider Name
Provider Address Street
City
State
ZIP
Provider Identifiers
Provider Federal Tax Identification Number (TIN)
or Employer Identification Number (EIN)
National Provider Identifier (NPI)
Provider Contact Information
Provider Contact Name
Title
Telephone Number
Fax Number
Email Address
Financial Institution Information
Financial Institution Name
Financial Institution Routing Number
q Checking
Type of Account at Financial Institution q Savings
Provider’s Account Number with Financial Institution
Submission Information
q New Enrollment
Reason for Submission
Included with Enrollment Submission* q Change Enrollment
q Voided Check q Cancel Enrollment
q Bank Letter
Authorized Signature
Written Signature of Person Submitting Enrollment
Printed Name of Person Submitting Enrollment
Printed Title of Person Submitting Enrollment
Submission Date
Requested EFT Start/Change/Cancel Date
Provider expressly authorizes Health Net Federal Services, LLC (Health Net) to credit entries (or if necessary, debit entries and
adjustments for any credit entries made in error) to the above referenced bank account number. Provider accepts responsibility for
any resulting loss of payment and releases Health Net of any liability for or arising from provider’s failure to submit accurate or
updated information to Health Net relating to the bank account. This authorization is to remain in effect until a new form, indicating EFT
cancellation or change (see above) is submitted to Health Net. The termination or change shall be effective 10 days subsequent to Health
Net’s receipt of the updated form.
* Voided check or bank letter verifying the financial institution information must be included when submitting this form.
Fax completed form to (916) 353-6829.
V1.0
Instructions:
Please type in the appropriate fields to complete form. Allow four weeks for the registration process, which includes pre-note
verification. If after four weeks you do not start receiving EFT, please contact the Health Net Finance Department at (916) 294-4837.
Provider Information
Provider Name – Please fill out completely.
Provider Address – complete legal name of institution, corporate entity, practice or individual provider
Street – the number and street name where a person or organization can be found
City – city associated with provider address field
State – character code associated with the state, two letter abbreviation
ZIP Code – postal zone code
Provider Identifiers
Provider Federal Tax Identification Number (TIN) – a federal tax identification number or employer identification number (EIN)
used to identify a business nine digits
National Provider Identifier (NPI) – HIPAA unique provider identifier with 10 digits
Provider Contact Information
Provider Contact Information – name, title, phone number and email address of the person authorized to provide the EDI staff with
information that relates to EFT payments or inquiries
Financial Institution Information
Financial Institution Name – Enter the designated financial institution name.
Financial Institution Routing Number – Enter the bank routing transit number.
Type of Account at Financial Institution – Indicate whether the account your EFT payments will be deposited to is a checking or savings
account. Check only one box.
Provider Account Number with Financial Institution – Enter the bank account number (not to exceed 17 digits).
Reason for Submission
Must select one from the below by checking the appropriate box on the form:
New Enrollment – Select this option to establish a new EFT account.
Change Enrollment – Select this option to change the bank account from which your EFT payments are made.
Cancel Enrollment – Select this option to cancel your enrollment and terminate EFT payments.
Included with Enrollment Submission
Check appropriate box and include a copy of a voided check if checking account being used or a bank letter.
Authorized Signature
Written Signature of Person Submitting Enrollment – signature of preparer or responsible individual in blue or black ink
Typed Name of Person Submitting Enrollment – typed name of preparer or responsible individual
Typed Title of Person Submitting Enrollment – title of the person who signs the form
Submission Date – date submitted for enrollment
Requested EFT Start/Change/Cancel Date – date for the requested action to become effective – Please allow four weeks for the
registration process, which includes pre-note verification. For termination or changes, please allow 10 days subsequent to Health Net’s
receipt of an updated form.
Note: An Electronic Remittance Advice (ERA) cannot be provided at this time. Once ERA capability exists, Health Net may request
additional information related to the ERA process. A paper remittance advice will be provided until the ERA process has been established.
For questions about this form, please call the Health Net Finance Department at (916) 294-4837.
VF0514x054
(10/14)
Fax completed form to (916) 353-6829. V1.0