ࡱ> cfba Ebjbj )fxEbxEb{ ?n n 86lt"ff| """""""$5$&b,"]",""F""2 ~ ,GFJ !"0"R ,M'\M'~ M'~ t,",""M'n B : Authorization Agreement for Electronic Funds Transfer (EFT) Part I DSHS Social Service Providers Only Please Choose One:  FORMCHECKBOX  Applies to ALL Social Service locations with this tax ID  FORMCHECKBOX  Applies to ONLY the Social Service address listed. If you are not updating all of the Social Service locations under this tax ID you will need to submit an EFT form for each location. Note: This section must be filled out for the form to be complete. ALL providers Please Choose One:  FORMCHECKBOX  New Enrollment  FORMCHECKBOX  Change Enrollment  FORMCHECKBOX  Cancel EFT Enrollment Part II Legal Name or Legal Organization Name (see W-9)  FORMTEXT       National Provider Identifier (NPI)  FORMTEXT       Business Name (DBA) if different from Legal Organization Name above  FORMTEXT       Physical Street Address  FORMTEXT       Federal Tax ID: SSN/FEIN  FORMTEXT       City  FORMTEXT       Provider Name Title  FORMTEXT       State/Province Zip Code + 4  FORMTEXT       Telephone Number (with Area Code)  FORMTEXT       Part III Financial Institution Name  FORMTEXT       Financial Institution Routing Number  FORMTEXT        FORMCHECKBOX  Checking  FORMCHECKBOX  Savings account Account Type (Will default to CCD if no option is checked)  FORMCHECKBOX  PPD (Personal)  FORMCHECKBOX  CCD (Corporate/Business) Provider Financial Institution Account Number  FORMTEXT       Part IV Electronic Remittance Advice (HIPAA 835). This section does not apply to DSHS Social Service Providers.  FORMCHECKBOX  EDI/835 Delivered directly to provider (You will need a Trading Partner Agreement (TPA) this agreement can be found at: https://www.hca.wa.gov/billers-providers-partners/forms-and-publications.) Part V I hereby authorize and request Washington State to initiate credit entries to my account indicated above, and the depository named above is authorized to credit such account. 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If any action taken by me, without adequate notification to Washington State, results in non-acceptance of the transfer by the designated financial institution, I understand that Washington State assumes no responsibility for processing supplemental payments until the funds are returned to Washington State by the financial institution. This authority will continue until Washington State has had a reasonable opportunity to act upon my written request to terminate EFT service or until Washington State determines that the required qualifications for enrollment are no longer being maintained. Authorization (Print) Title (Print) Authorization Signature Date Of Submission  FORMTEXT       PLEASE MAIL OR FAX FORM TO: HCA  MEDICAID PO BOX 45562 OLYMPIA, WA 98504-5562 FAX (360) 725-2144      SHAPE \* MERGEFORMAT  HCA 12-0004 (7/19) FCHCJCxCCgA%  T Kdh"$1$3$5$7$8$H$If^KgdH,K$" R Kdh"$1$3$5$7$8$H$If^Kgd%*cK$7kd$IfK$L$hr*m*# # # # aytF}%  T adh"$1$3$5$7$8$H$If^agdK$ad$7$8$H$If^agdF}vCxCCCCCCCCCDDDDDDDJDLDNDDıseWI;hx;h%*c5CJ^JaJhx;hF}5CJ^JaJhx;h5CJ^JaJhx;hP5CJ^JaJ0jh@hhCJPJU^JaJmHnHu+jh@hhCJPJU^JaJh@hhCJPJ^JaJ%jh@hhCJPJU^JaJhhCJ^JaJ h`ghCJOJPJQJaJhhCJ^JaJ%h`ghB*CJPJ^JaJph# CCCDh%  T Kd"$1$3$5$7$8$H$If^KgdhK$%  T Kdh"$1$3$5$7$8$H$If^Kgd`gK$JkdW$IfK$L$0ir*d # # # # # # # # aytDDDDEhE# \ d$-D7$8$H$IfM ^gd# \ d$-D7$8$H$IfM ^gd%*c) \ d<$-D7$8$H$IfM ^`gdJkd1$IfK$L$0ir*d # # # # # # # # aythDDDEEEEEEE E"E&E(E,E.E\E^E`EbEdEfEhEEEEEǿhhphpCJaJhx;jh/.Ujh/.UmHnHuh/.jh/.Uhs$jhs$Uhx;h%*cCJ^JaJhx;h<CJ^JaJhx;hF}CJ^JaJ h%*c5^Jh%*ch%*c5^JEEEEEE E$E&E*E,EfEhEEEEEgdpxgdH, dgdIYgdDkd$$IflL*P+ t44 laytI5 01h:p&/ =!"#$%h nk4(<( BPNG  IHDR)c&MsRGB@} pHYs+tEXtSoftwareMicrosoft Office5qYIDATxm۶m۶m۶m۶m۶u{Oߚ?3=d7<2 ;nz3|^H~{:묳>6pôb駟>=i衇N_֭[>駟4PC/9iuM~x~G}T{zon7pC/k't뭷vm?TGn喴[Խϧ.,=SN9%miO;ndAjǀ{t綑La&tA\sM~ꫯ##4R;Hn׎8ٞw9]>19:>iAM6[J+}ݷw試*q-I ?cz'ҩ_4teYAF,Oi=fyK/7\s;n9dRo]'}|MgOOtgalwo{.ϲڦ?}3xXb4h5J BKi]vIw\Kӝwޙcz,C~a+iN.lk%eg_}r!kfӪ:kLFa.{>Y/5axӨ;2#{,kR_dEK3@O?=ֈwgM3=|ȅZ(c]iPb{oXz$g^oj)ڌe_{hOyς˼?+ӳ> 0c9&O>f{}Vy.&,_c. ˛o-*] 7Ҹ[B^qLa6!q3=35_g:; /֬#뇿w/0S=أfctaod-Zk5F\jQ[ou:+-ْj{l6g2I\pafV-&{JEw=ooxOpy#&Ampye-?,+"??Ú'q@h0v#b@KK@eQ{pٻ?C~&!q +W28җ'29 ҫfeʷ#Xbyfi%VpYlY!o=T'|r1.M BR :;lM#8bܲp71.ݶ>DYcLvvW-*4A4]R۳k BB+ iW>{WABd`EV4*؉kUd3RPz&-W5H G=XbຬNby ȔHWU+WG!=J },W=QR XN HͿs d]Վ=;ϪkʗYPrKz54a=30*!U2%'xb祡D(h2+VjW_ PubJ/#{P*56ZBWUȩW Y9*( L+`O4k 'b):1m s-NG. 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