Electronic Funds Transfer

Electronic Funds Transfer
Electronic Funds Transfer, also known as EFT, is a paperless payment option that most insurance companies are providing. Funds due to your practice are directly deposited into your bank account for faster and more efficient payment. Please complete the form(s) of your choice for enrollment and submit each document directly to the insurance company as advised.
Practice Name *
Practice Tax ID Number *
Practice NPI*
Practice Email*
example@example.com
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Plans to initiate EFT (225.00 each) *
Voided Check*

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