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EFT Online Enrollment Form


The provider must contact its financial institution to arrange for the delivery of the CORE required Minimum CCD+ data elements needed for reassociation of the payment and the ERA. See Phase III CORE EFT & ERA Reassociation (CCD+/835) Rule Version 3.0.0.


* indicates required field

Provider Information
*Provider Name:
Please fill out completely. Complete legal name of institution, corporate entity, practice or individual provider.
*Provider Street Address:
The number and street name where a person or organization can be found.
*City:
City associated with provider address field.
*State:
Character code associated with the State. 2 digits.
*Zip Code:
Postal zone code.
Provider Identifiers Information
*Provider Federal Tax
    Identification Number (TIN)
    or Employer Identification Number (EIN):
A federal tax identification number or Employer identification number used to identify a business 9 digits.
    National Provider Identifier (NPI#):
HIPAA unique provider identifier 10 digits.
*Provider Contact Name:
*Title:
*Telephone Number:
     Fax Number:
*Email Address:
Financial Institution Information
*Financial Institution Name:
Enter the designated Financial Institution name.
*Financial Institution Routing Number:
Enter the Bank routing transit number.
*Type of Account at Financial
     Institution:
  Checking        Savings
Indicate whether the account your EFT payments will be deposited to is a checking or savings account. Check only one box.
*Provider's Account Number
    with Financial Institution:
Enter the bank account number (not to exceed 17 digits).
*Please re-enter the Account Number:
 
*Account Number Linkage to Provider Identifier:** 
Provider preference for grouping (bulking) claim payments - must match preference for v5010 X12 835 remittance advice. Please select only one option.
Provider Tax Identification
       Number (TIN):
 
A federal tax identification number (TIN) or Employer identification number (EIN) Numeric, 9 digits.
National Provider Identifier (NPI#):  
Unique identification number for covered healthcare providers. Numeric, 10 digits.
Submission Information
*Reason for Submission:   New Enrollment        
Enrollment of new EFT account.

  Change Enrollment  
This information facilitates the registration transition from the old to the new bank account and expedites processing your bank account change.

  Cancel Enrollment    
Use to terminate receipt of EFT payments.
*Include with Enrollment Submission:   Voided Check             
Please include a copy of a voided check if checking account is being used.

  Bank Letter             
Please include a Bank Letter, if voided check is not available.

Authorized Signature
*Written Signature of Person
    Submitting Enrollment:
Signature of preparer or responsible individual.
*Printed Title of Person
    Submitting Enrollment:
Enter the title of the person who signs the form.
    Submission Date: 12/07/2021 
The date submitted for enrollment.
*Requested EFT Start/Change/
    Cancel Date:
 
Date for the requested action to become effective.

e.g.mm/dd/yyyy
*I agree with the following:
Provider expressly authorizes Managed Health Network (MHN) to credit entries (or, if necessary, debit entries and adjustments for any credit entries made in error) to the above-referenced Bank Account number. Provider accepts responsibility for any resulting loss of payment and releases MHN of any liability for or arising from Provider's failure to submit accurate or updated information to MHN relating to the Bank Account. This authorization is to remain in effect until written notice in the form of an EFT cancellation or change form is submitted to MHN. The termination or change shall be effective 10 days subsequent to Managed Health Network's receipt of the updated form.
**Must match ERA grouping