Eps Eft New Enrollment Authorization Agreement
1 EPS EFT Enrollment Authorization Agreement Optum improves service for you by replacing paper reviews and benefit reviews (EOBs) with Optum EPS. Get a head start by signing up today! For more information on this registration form, please see the registration instructions for electronic payments and bank statements by selecting the Connect tab on the Optum EPS website. Please enter this form directly or print it out clearly. Please fill in all necessary information. All fields are required. Supplier Information – Supplier Name: Supplier Address (P.O.Box Are Not Accepted) Suppliers Identified Information Provider Identifiers – Supplier Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): National Provider Identifier (NPI): Provider Type: Hospital/Facility Physician (Group/Individual Practice) Other Healthcare Services Organization (DME, Home Health Services, Laboratory Services, other) -Provider Type: Behavioral Health Dental Medical Vision Other Provider Contact Information -Provider Contact Information: `Telephone Number: Number Extension: `Address: Secondary Provider Contact Secondary contact is not necessary to complete the registration process. However, if a secondary contact is added, all fields are required. Supplier Contact Name: Phone Number: Extension Phone Number: Address: Financial Institution Financial Institution Financial Institution Information for your TIN: This section of the financial institution collects banking information for payments made to your paid TIN provider/organization. Account number Link to ISP ID: Supplier Tax Identification Number (TIN) in the Logan County Bank-Online-Banking-Vereinbarung Supplier Information section und Offenlegungsn zu UNSEREN PERS-NLICHEN BANKING-KUNDEN: You must accept this agreement before connecting to the „First User Access“ screen. If you do not have 4 electronic payments and statements terms/terms and statements The following terms and conditions, amended from time to time (agreement) apply to the total use of OptumHealth Financial Services, Inc. electronic payments and account extracts, and the use of all services related to it (with EPS services). In this agreement, the terms that you and your people specify to the organization, to the entity or entity and to the persons on the electronic payment and extract registration form (registration form) that you have forwarded to us or that you subsequently identify as primary or other users, and the words we refer to as OptumHealth Financial Services, Inc., their affiliates, design partners and other service providers (Optum set).
Your registration in EPS services and the use of EPS services are your legal commitment agreement related to this agreement. ACH payments. This agreement is governed by Article 4A of the Single Code of Trade (UCC). By accepting this agreement, if you give us your account information (as defined below) we, authorize directly or indirectly, on behalf or through an external administrator, a public health coalition, an external carrier or another external carrier or payer (a third party) or a single consumer or other person (individual payer and collective payer), to authorize the transfer or charge of the account on your registration form (account or account) related to the processing of transactions between you and a payer. We can rely on the account information and identification numbers you have listed on the registration form to receive the payment. We can count on the routing and account numbers you have provided, even if they identify a financial institution, person or account other than the one mentioned in the registration form. They agree to comply with all applicable laws, rules and guidelines regarding electronic transfers of funds, including, but not limited to, UCC Section 4A and the National Automated ClearingHouse Association`s operating rules and rules.