Tutorial for Electronic Funds Transfer Authorization Agreement

Tutorial for Electronic Funds Transfer Authorization Agreement • This tutorial is designed to walk you through the process of completing the Electronic Funds Transfer (EFT) Authorization Agreement. • All sections must be completed so that we can process your EFT.

Please check the appropriate box. If this is the first time you are completing this EFT form for WPS, please check “New EFT Authorization”.

Be sure to complete all lines that apply to you. The Medicare Identification number is your Medicare billing provider number or group number. If you have not established a Medicare number, enter “pending”.

A pre-printed voided check or letter from your bank is preferred. The routing number on a deposit slip is usually invalid for direct deposits. The routing number and account number you enter on this form must match the account verification you send along with this EFT request. The address on the check must be your current address or an explanation is required.

This should be the person we can contact if we have any questions and to notify of EFT setup.

Enter WPS as the contractor in the blank line.

This must be signed by your authorized or delegated official. If you don’t know who this is, please contact our Provider Enrollment dept: Illinois, Michigan and Wisconsin providers: 1-877-908-8476 Minnesota providers: 1-866-564-0315 This must also be an original signature.

When your form is completed, attach your bank account verification and mail to: Part B providers WPS EDI 8120 Penn Ave South, Suite 200 Bloomington, MN 55431 Part A providers WPS Medicare Finance Department PO Box 1602 Omaha, NE 68101 Faxed copies cannot be accepted

This concludes the tutorial.

Tutorial for Electronic Funds Transfer Authorization Agreement