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STATE OF ARIZONA – ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM Electronic Funds Transfer (EFT) Authorization Agreement Attn: AHCCCS Finance- MD 5400, P.O. Box 25520, Phoenix, AZ 85002 Fax Number: 602-258-5943 * REQUIRED FIELD + REQUIRED FIELD IF SECTION IS APPLICABLE PROVIDER IDENTIFIER INFORMATION Provider Name * ________________________________________________ Doing Business As Name (DBA) ___________________________________________ 1 Provider Address __________________________________ ___________________ ____________________ _______________________ Street * City * State/Province * Zip Code/Postal Code * SECTION Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) * National Provider Identifier (NPI)* Trading Partner ID(AHCCCS Provider Number)* PROVIDER CONTACT INFORMATION _______________________________________________________________ ___________________________________________________ 2 Provider Contact Name * Title SECTION _______________________________________ Telephone Number & Extension* ________________________________________________________________ ________________________________ Email Address * Fax Number PROVIDER AGENT INFORMATION - IF APPLICABLE Provider Agent Name + ________________________________________________ ________________________________ _____________________ ____________________ ___________________________ Agent Address Street + City + State/Province + Zip Code/Postal Code + 3 ___________________________________________________ _______________________________ SECTION Provider Agent Contact Name + Title ________________________________________ Telephone Number & Extension + ________________________________________________________________ _____________________________________ Email Address + Fax Number FINANCIAL INSTITUTION INFORMATION Financial Institution Name * ________________________________________________________________ _________________________________________________ ____________________ ____________________ _______________________________ Financial Institution Address Street * City * State/Province * Zip Code/Postal Code * ____________________________________________________ Financial Institution Telephone Number & Extension 4 Financial Institution Routing Number * SECTION Type of Account at Financial Institution * Checking _____ Savings _____ Provider's Account Number with Financial Institution * Account Number Linkage to Provider Identifier * Provider's Federal Tax Identification Number OR National Provider Identifier Number SUBMISSION INFORMATION 5 Reason for Submission * New Enrollment _____ Change Enrollment _____ Cancel Enrollment _____ SECTION Include with Enrollment Submission * Voided Check - A voided check is attached to provide confirmation of identification/account numbers OR ______ Bank Letter - A letter on bank letterhead that formally certifies the account owners routing and account numbers AUTHORIZATION Pursuant to A.R.S. Sec. 35-185, I authorize theArizona Department of Administration (ADOA, General Accounting Office (GAO) and the Arizona Health Care Cost Containment System (AHCCCSA) to process payments owed to me via Automated Clearing House (ACH) deposits. The State of Arizona and AHCCCSA shall deposit the ACH payments in the financial institution and account designated above. * I recognize that if I fail to provide complete and accurate information on this authorization form, the processing of the form may be delayed or made impossible, or my electronic payments may be erroneously made. I authorize the State of Arizona and AHCCCSA to withdraw from the designated account all amounts deposited electronically in error in accordance with NACHA rules and timelines. If the designated account is closed or has an insufficient balance to allow withdrawal, then I authorize the State of Arizona and AHCCCSA to withhold any payment owed to me by the State of Arizona and AHCCCSA until the 6 erroneous deposited amounts are repaid. If I decide to change or revoke this authorization, I recognize that I must forward such notice to AHCCCSA, Attn: Finance Dept., Mail Drop 5400, P.O. Box 25520, Phoenix, AZ 85002. The change or revocation is effective on the day that ADOA/GAO and AHCCCSA process the request. SECTION I certify that I have read and agree to comply with the State of Arizona and AHCCCSA’ s rules governing payments and electronic transfers as they exist on the date of my signature on this form or as subsequently adopted, amended, or repealed. I consent to, and agree to, comply with these rules even if they conflict with this authorization form. I authorize the State of Arizona and AHCCCSA to stop making electronic transfers to my account without advance notice. I certify that I am authorized to contract for the entity receiving deposits, pursuant to this agreement, and that all information provided is accurate. The financial institution can process CCD+ payments/transactions along with addendum information. * Yes _____ No_____ ______________________________________ _______________________________________ _________________________________________ Authorized Signature * Print Name of Authorized Signer * Title Submission Date * ________________________________________ Requested EFT Start/Change/Cancel Date * ____________________________________ Revised 9/23/2015