Authorization Agreement for Electronic Funds Transfers (EFTs)

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Section 1: Provider Information

Either Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)

Provider may list multiple NPI #'s if they share the Federal Tax ID listed above and Bank Account listed below. A separate Implementation form needs to be completed for each unique bank account and Federal Tax ID. Enter each NPI number on its own line.

Section 2: Provider Contact Information (Name of a contact in provider's office for handling EFT issues)

Section 3: Financial Institution Information

You will receive an EFT for each Billing NPI

Section 4: Submission Information

The information contained within this form will be applied to all applicable contracts with Quartz Health Benefit Plans Corporation, Quartz Health Solutions, Inc., Quartz Health Plan Corporation, Quartz Health Plan MN Corporation, and Quartz Health Insurance Corporation.

Authorized Signature

*Indicates a required field