Electronic Funds Transfer (EFT) Authorization and Change Form

Authorization Agreement for Electronic Funds Transfer (EFT)

Established vendors can use this standalone EFT authorization to initialize, change, or cancel their EFT status. Non-established vendors should not complete this form but must instead submit the Vendor Setup Packet, which includes EFT authorization.
Request type
What is the nature of this request?

Initialize EFT (established vendors only)Change EFT informationCancel EFT authorization
Vendor information

Both the legal name and TIN should match Alliance Health records. If the vendor legal name you listed is an individual, generally your taxpayer identification number (TIN) is your social security number (SSN). For other entities, it is your employer identification number (EIN).
Legal name*
Mailing address

Street Address

Street address line 2

CityState

Postal code
Which type of Tax identification number (TIN) is associated with your business?*
If the vendor legal name you listed is an individual, generally your taxpayer identification number (TIN) is your social security number (SSN). For other entities, it is your employer identification number (EIN).
Tax ID*
Social security number (SSN)*
Remittance email
example@example.com
Phone
Please enter a valid phone number.
Financial institution information
Account holder's name*
Routing number*
Account number*
Type of account*

CheckingSavings
Financial institution name*
We request that you include a blank, voided check or bank-generated account verification form for account and routing number verification.
Are you attaching a blank, voided check or a bank-generated account verification form?*

YesNo
If neither of these documents are provided as requested, Alliance Health does not accept responsibility for the accuracy of the above typed/written account information submitted.
Upload Voided Check or Bank-generated Account Verification*

Cancelof
Blank check PDF upload notification
Authorization
Please select to authorize or cancel this EFT below:

This authorization is effective as of the signature date below and is to remain in full force and effect until AllianceHealth has received written notification of its termination in such time and such manner as to afford Alliance Health and the financial institution a reasonable opportunity to act on it, or until Alliance Health deems it necessary to terminate this agreement. Under penalties of perjury, I hereby certify the checking OR savings account indicated on this form are under my direct control and access; therefore, I authorize Alliance Health to initiate, change, or cancel credit entries to the financial institution account as indicated above. If my financial institution information changes, I agree to submit to Alliance Health a revised Authorization Agreement for Electronic Funds Transfer form.I hereby CANCEL my EFT authorization.
I understand that by signing this form, payments issued will be Federal and State funds, and that any falsification or concealment of a material fact may be prosecuted under Federal and State laws.
Print name*
Signature*

Clear
Should be Empty:

Authorization Agreement for Electronic Funds Transfer (EFT)

Request type

Vendor information

Financial institution information

Authorization