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EFT Online Enrollment Form

The provider must contact its financial institution to arrange for the delivery of the CORE required Minimum CCD+ data elements needed for reassociation of the payment and the ERA. See Phase III CORE EFT & ERA Reassociation (CCD+/835) Rule Version 3.0.0.

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Provider Information


Provider Identifiers Information


Provider Contact Information


Financial Institution Information


Submission Information


Authorized Signature

I agree with the following*