Fillable Printable Electronic Funds Transfer Authorization Agreement Form
Fillable Printable Electronic Funds Transfer Authorization Agreement Form
Electronic Funds Transfer Authorization Agreement Form
Fax Number: 602-258-5943
* REQUIRED FIELD + REQUIRED FIELD IF SECTION IS APPLICABLE
Provider Name * ________________________________________________ Doing Business As Name (DBA) ___________________________________________
City * State/Province *
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) *
Fax Number
Provider Agent Name + ________________________________________________
Agent Address Street + City + State/Province +
Fax Number
Financial Institution Address Street * City * State/Province *
Financial Institution Routing Number *
Type of Account at Financial Institution * Checking _____ Savings _____
Provider's Account Number with Financial Institution *
Account Number Linkage to Provider Identifier *
OR
National Provider Identifier Number
Reason for Submission *
Include with Enrollment Submission * ______ Voided Check - A voided check is attached to provide confirmation of identification/account numbers
OR
______________________________________ _______________________________________ _________________________________________
Title
Submission Date * ________________________________________ Requested EFT Start/Change/Cancel Date * ____________________________________
________________________________________________________________ ________________________________
Email Address *
STATE OF ARIZONA – ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
Electronic Funds Transfer (EFT) Authorization Agreement
Attn: AHCCCS Finance- MD 5400, P.O. Box 25520, Phoenix, AZ 85002
PROVIDER IDENTIFIER INFORMATION
Provider Address __________________________________ ___________________ ____________________ _______________________
Street *
SECTION 1
National Provider Identifier (NPI)*
________________________________________________________________ _____________________________________
SECTION 2
PROVIDER CONTACT INFORMATION
_______________________________________________________________ ___________________________________________________
Provider Contact Name *
Title
_______________________________________
Telephone Number & Extension*
Financial Institution Telephone Number & Extension
SECTION 3
PROVIDER AGENT INFORMATION - IF APPLICABLE
____________ _ _ _ __ _ _ __ _ _ __ _ _ __ _ _ _ _ _ _ __ _ _ __ _ _ __ _ _ __ _ _ __ _ _ _ __ _ _ __ _ _ __ _ _ __ _ _ _ _ _ _ __ _ _ __ _ _ __ _ _ __ _ _ __ _ _ __ _ _
___________________________________________________ _______________________________
Provider Agent Contact Name +
Title
________________________________________
Telephone Number & Extension +
I authorize the State of Arizona and AHCCCSA to stop making electronic transfers to my account without advance notice.
I certify that I am authorized to contract for the entity receiving deposits, pursuant to this agreement, and that all information provided is accurate.
SECTION 5
SUBMISSION INFORMATION
New Enrollment _____
Change Enrollment _____
Cancel Enrollment _____
SECTION 4
Financial Institution Name * ________________________________________________________________
SECTION 6
AUTHORIZATION
Pursuant to A.R.S. Sec. 35-185, I authorize theArizona Department of Administration (ADOA, General Accounting Office (GAO) and the Arizona Health Care Cost Containment System (AHCCCSA) to
process payments owed to me via Automated Clearing House (ACH) deposits. The State of Arizona and AHCCCSA shall deposit the ACH payments in the financial institution and account designated above.
* I recognize that if I fail to provide complete and accurate information on this authorization form, the processing of the form may be delayed or made impossible, or my electronic payments may be
erroneously made.
______ Bank Letter - A letter on bank letterhead that formally certifies the account owners routing and account numbers
I authorize the State of Arizona and AHCCCSA to withdraw from the designated account all amounts deposited electronically in error in accordance with NACHA rules and timelines. If the designated
account is closed or has an insufficient balance to allow withdrawal, then I authorize the State of Arizona and AHCCCSA to withhold any payment owed to me by the State of Arizona and AHCCCSA until the
erroneous deposited amounts are repaid. If I decide to change or revoke this authorization, I recognize that I must forward such notice to AHCCCSA, Attn: Finance Dept., Mail Drop 5400, P.O. Box 25520,
Phoenix, AZ 85002. The change or revocation is effective on the day that ADOA/GAO and AHCCCSA process the request.
I certify that I have read and agree to comply with the State of Arizona and AHCCCSA’ s rules governing payments and electronic transfers as they exist on the date of my signature on this form or as
subsequently adopted, amended, or repealed. I consent to, and agree to, comply with these rules even if they conflict with this authorization form.
Provider's Federal Tax Identification Number
Zip Code/Postal Code *
Email Address +
FINANCIAL INSTITUTION INFORMATION
____________________________________________________
_________________________________________________ ____________________ ____________________ _______________________________
Authorized Signature *
Print Name of Authorized Signer *
Zip Code/Postal Code +
Zip Code/Postal Code *
Trading Partner ID(AHCCCS Provider Number)*
The financial institution can process CCD+ payments/transactions along with addendum information. * Yes _____ No_____
Revised 9/23/2015
