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EFT Online Enrollment Form


If you are a participating MHN network provider and have a account, please log in before enrolling in EFT or ERA.  Failure to do so will delay processing and could result in a rejection.


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*