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EFT Payment Information Form

Providers currently set up for electronic remits are eligible to receive electronic fund transfers (EFT). To enroll or make changes to an EFT account, complete and submit this form. Forms must be received by the 15th of the month to begin depositing payment directly to your account by EFT the following month. A confirmation letter will be sent once your request is processed. Requests are processed on a monthly basis.

EFT Form Instructions


* Indicates a required field.


PROVIDER INFORMATION

 

 

FINANCIAL INSTITUTION INFORMATION

 

I hereby certify that I am an authorized signer on behalf of the above named Provider. I also certify that BCBSWY is authorized to enter transactions into the above account. This authorization is to remain in effect until a 30-day written notice is given to BCBSWY to cease these transactions.

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