Electronic Funds Transfer (EFT) Authorization Agreement Fax-Name Required fields Provider Information Provider Name: Provider Identifiers Information Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): National Provider Identifier (NPI): Provider Contact Information Provider Contact Name: Telephone Number: Email Address: Fax Number: Financial Institution Information Financial Institution Name: Financial Institution Routing Number: Type of Account at Financial Institution: Select Checking Savings Provider's Account Number with Financial Institution: Account Number Linkage to Provider Identifier: Select Provider Tax Identification Number National Provider Identification Number Provider Tax Identification Number (TIN): National Provider Identifier (NPI): Submission Information Reason for Submission: Include with Enrollment Submission: Select Bank Letter Voided Check Select an image of your check or bank letter to upload: File types: jpg, png, gif, pdf Maximum total file size: 20MB aria-label for wcag fix Authorized Signature Printed Name of Person Submitting Enrollment: Printed Title of Person Submitting Enrollment: Authorization By signing above, I hereby authorize Hawaii Medical Service Association, hereinafter called the COMPANY, to initiate credit entries, and initiate adjustments for any credit entries made in error to the account indicated above. I hereby authorize the financial institution/bank named above, hereinafter called the DEPOSITORY, to credit and/or debit the same to such account. I certify that the account is used solely for business purposes. This authorization agreement will be effective within ten (10) days of acceptance by the Depository and is to remain in full force and effect until the COMPANY has received written notification from me of its termination in such time and such manner as to afford the COMPANY and the DEPOSITORY a reasonable opportunity to act on it. The COMPANY will continue to send the direct deposits to the DEPOSITORY indicated above until notified by me that I wish to change the DEPOSITORY receiving the direct deposit. If my DEPOSITORY information changes, I agree to submit to the COMPANY an updated EFT Authorization Agreement. Captcha is not valid. Please try again. Cancel