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Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Authorization Agreement
Please select one option and enter the corresponding number in the space provided.
Please indicate the name of the clearinghouse that you are registered with for receiving 835s by checking one of the boxes below. Note: Prior to submission of this Agreement, you must register with a clearinghouse to receive 835s. Itasca Medical Care cannot send 835s to your clearinghouse until you have registered.
I hereby authorize Itasca Medical Care to deposit, by electronic fund transfer, payments owed to the aforementioned provider or supplier by Itasca Medical Care and, if necessary, debit entries and adjustments for any amounts deposited in error. Itasca Medical Care shall deposit the payments in the designated financial institution’s account. I recognize that if I fail to provide complete and accurate information on this Authorization Agreement, the processing of the Agreement may be delayed or my payments may be erroneously transferred electronically. Itasca Medical Care shall have no liability or responsibility for any payments erroneously transferred.
This Authorization Agreement is effective as of the signature date below and is to remain in full force and effect until Itasca Medical Care has received written notification from our organization’s authorized agent of its termination in such time and such manner as to afford Itasca Medical Care and the financial institution a reasonable opportunity to act on it. Itasca Medical Care will continue to send the direct deposit to the financial institution indicated above until notified of a change to the financial institution receiving the direct deposit. If the financial institution information requires changes, an updated Authorization Agreement must be submitted to Itasca Medical Care.
I affirm all of the information contained in this enrollment application to be correct and true to the best of my knowledge. I understand that providing false or misleading information on this enrollment application will result in rejection from the EFT payment program and that I will be responsible for any fees, legal or otherwise, incurred by Itasca Medical Care on my behalf.
NO BALANCE BILLING TO PATIENT. By accepting Itasca Medical Care payments, you agree to only bill or attempt to collect from the member any unpaid amounts on any remittance indicated as "member responsibility."
Please make sure this Authorization Agreement is filled out completely and that a voided check or a bank letter will be sent to Itasca Medical Care.
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