By signing above, I hereby authorize Hawaii Medical Service Association to send 835 transactions which includes claims information and payment information. I attest that all information in this authorization agreement is true, accurate and complete. This Authorization is to remain in effect until written notice in the form of an ERA Authorization Agreement form marked as a cancellation or change form is submitted to Hawaii Medical Service Association. Any changes to provider's agent, clearinghouse or vendor must be submitted on an ERA Authorization Agreement form as a change. The termination or change shall be effective 20 days subsequent to Hawaii Medical Service Association's receipt of the updated form.