Electronic Funds Transfer (EFT) automatically deposits your Medicare claim payments directly into your bank account. To sign up for EFT, you must complete an Authorization Agreement for Electronic Funds Transfer.

 

Complete the form and have it signed and dated by the provider or the authorized/delegated official if this is for a group or organization. The signature must be original (copied, faxed or stamped signatures are not acceptable).

 

Under the Physician/Provider/Supplier Information you are asked to provide your Medicare Identification Number. Please provide your GHI Medicare Provider Identification Number (PIN). This field can be left blank if you are submitting the EFT form with an initial enrollment application (CMS 855I or CMS 855B).

 

For verification of your account number, one of the following must also be attached:

 

A group does not need to submit an EFT form for each of its members. Only the group submits the form and should indicate the group’s PIN in the Medicare Identification Number field.

 

This form should also be used to revise accounts or banks. Complete a new EFT agreement. Under the Reason for Submission, check the box for "Revision to Current Authorization" and complete the form using the new account information. Attach the documentation required to verify your account number.

Medicare carriers can not approve any requests to change payment method from EFT to check. Providers and suppliers may revise a current EFT authorization or make such changes necessary to continue payment via EFT (e.g. changing financial institutions).

If the EFT Authorization Agreement form is incomplete, it will be returned with a letter explaining the errors or omissions identified, without further processing.

 

Completed forms may be mailed to:

 

GHI Medicare

25 Broadway, floor 12

New York, NY 10004-1010

Attn: Provider Enrollment Unit

 

It takes approximately 2-3 weeks to fully process your EFT application.