Instructions for completing the EFT Page.
Select the Application Type from the left navigation menu.
Complete all sections below and upload a copy of a voided check or a signed letter from your bank-on-bank letterhead.
If you do not wish to be reimbursed electronically, you may select “I do not wish to participate in the EFT program.” This will opt you out and paper checks will be mailed to your accounting/billing address.
The following fields are pre-populated or filled out for you using information you provided on the Participant Information and Accounting/Billing Information pages.
Provider name
Doing Business As
Street
City
State
Zip Code/Postal Code
Country Code
Provider Identifiers Information
The following fields are either pre-populated/fill out for you or not required for ITP registrants.
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): this field is prepopulated from the W9 page.
National Provider Identifier: this field is prepopulated from the NPI on the NPI/Taxonomy page.
Provider Type: This field is prepopulated as ITP
Provider License Number: this field is not required
License Issuer: this field is not required
Provider Taxonomy Code: this field is not required
Assigning Authority: this field is prepopulated as Medicaid.
Trading Partner ID: this field is not required
Other Identifier: this field is not required
Contact Information
Contact Name: Enter your first and last name
Title: this field is not required
Email Address: Enter your email address
Phone Number: Enter your phone number
Extension: Enter your phone number extension, if you have one
Fax Number: Enter your fax number, if you have one
Agent Information
The following fields are not required for ITP registrants.
Agent Name: this field is not required
Agent Contact Name: this field is not required
Title: this field is not required
Street: this field is not required
City: this field is not required
State: this field is not required
Zip Code: this field is not required
Zip Code +4: this field is not required
Country Code: this field is not required
Email Address: this field is not required
Agent Phone Number: this field is not required
Agent Phone Number Extension: this field is not required
Agent Fax Number: this field is not required
Federal Agency Information:
The following fields are not required for ITP registrants.
Federal Program Agency Name: this field is not required
Federal Program Agency Identifier: this field is not required
Federal Program Agency Code: this field is not required
Retail Pharmacy Information
The following fields are not required for ITP registrants.
Pharmacy Name: this field is not required
Chain Number: this field is not required
Parent Organization Name : this field is not required
Payment Center ID: this field is not required
NCPDP Provider ID Number: this field is not required
Medicaid Provider Number: this field is not required
Financial Institution Information
Financial Institution Name: Enter the name of your Bank
Account Number: Enter the account number for your bank account
Routing Number: Enter the routing number for your bank account
Type of Account: Select Checking or Savings from the available drop-down menu
Account Number Linkage to Provider Identifier: Select either Provider Tax Identification Number or National Provider ID (NPI):
If you select Provider Tax Identification Number. This will be pre-populated from the W9 form page.
If you select National Provider ID (NPI), this will be pre-populated from the NPI/Taxonomy page.
A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
Street: Enter the street for your bank
City: Enter the City for your bank
State: Enter the State for your bank
Zip Code: Enter the Zip Code for your bank
Zip Code +4: Enter the Zip Code +4 for your bank, if you have this information.
Contact Phone Number: Enter the Contact Phone number for the bank
Extension: Enter the extension for the Phone Number for the bank, if applicable.
Submission Information
Reason for submission:
New Enrollment
Change Enrollment
Cancel Enrollment
Include with Enrollment Submission: Select the attachment you will be sending with your bank information.
Voided Check: This will be a blank check with your address, routing, and account number information clearly shown.
Bank Letter: This is a letter from your bank that shows your account information.
Authorized Signature
You must electronically sign this document on the Agreement page.
For any required documents, select "Click here to select files".
Click Save.
Once all subpages have been completed, use the left navigation arrow in the blue header to return to the main page navigation. Then select the next available page to continue entering your application
Instructions for completing the EFT Page.
Complete all sections below and upload a copy of a voided check or a signed letter from your bank-on-bank letterhead.
If you do not wish to be reimbursed electronically, you may select “I do not wish to participate in the EFT program.” This will opt you out and paper checks will be mailed to your accounting/billing address.
The following fields are pre-populated or filled out for you using information you provided on the Participant Information and Accounting/Billing Information pages.
Provider name
Doing Business As
Street
City
State
Zip Code/Postal Code
Country Code
Provider Identifiers Information
The following fields are either pre-populated/fill out for you or not required for ITP registrants.
Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN): this field is prepopulated from the W9 page.
National Provider Identifier: this field is prepopulated from the NPI on the NPI/Taxonomy page.
Provider Type: This field is prepopulated as ITP
Provider License Number: this field is not required
License Issuer: this field is not required
Provider Taxonomy Code: this field is not required
Assigning Authority: this field is prepopulated as Medicaid.
Trading Partner ID: this field is not required
Other Identifier: this field is not required
Contact Information
Contact Name: Enter your first and last name
Title: this field is not required
Email Address: Enter your email address
Phone Number: Enter your phone number
Extension: Enter your phone number extension, if you have one
Fax Number: Enter your fax number, if you have one
Agent Information
The following fields are not required for ITP registrants.
Agent Name: this field is not required
Agent Contact Name: this field is not required
Title: this field is not required
Street: this field is not required
City: this field is not required
State: this field is not required
Zip Code: this field is not required
Zip Code +4: this field is not required
Country Code: this field is not required
Email Address: this field is not required
Agent Phone Number: this field is not required
Agent Phone Number Extension: this field is not required
Agent Fax Number: this field is not required
Federal Agency Information:
The following fields are not required for ITP registrants.
Federal Program Agency Name: this field is not required
Federal Program Agency Identifier: this field is not required
Federal Program Agency Code: this field is not required
Retail Pharmacy Information
The following fields are not required for ITP registrants.
Pharmacy Name: this field is not required
Chain Number: this field is not required
Parent Organization Name : this field is not required
Payment Center ID: this field is not required
NCPDP Provider ID Number: this field is not required
Medicaid Provider Number: this field is not required
Financial Institution Information
Financial Institution Name: Enter the name of your Bank
Account Number: Enter the account number for your bank account
Routing Number: Enter the routing number for your bank account
Type of Account: Select Checking or Savings from the available drop-down menu
Account Number Linkage to Provider Identifier: Select either Provider Tax Identification Number or National Provider ID (NPI):
If you select Provider Tax Identification Number. This will be pre-populated from the W9 form page.
If you select National Provider ID (NPI), this will be pre-populated from the NPI/Taxonomy page.
A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.
Street: Enter the street for your bank
City: Enter the City for your bank
State: Enter the State for your bank
Zip Code: Enter the Zip Code for your bank
Zip Code +4: Enter the Zip Code +4 for your bank, if you have this information.
Contact Phone Number: Enter the Contact Phone number for the bank
Extension: Enter the extension for the Phone Number for the bank, if applicable.
Submission Information
Reason for submission:
Update Enrollment
Change Enrollment
Cancel Enrollment
Include with Enrollment Submission: Select the attachment you will be sending with your bank information.
Voided Check: This will be a blank check with your address, routing, and account number information clearly shown.
Bank Letter: This is a letter from your bank that shows your account information.
Authorized Signature
You must electronically sign this document on the Agreement page.
For any required documents, select "Click here to select files".
Click Save.
Once all subpages have been completed, use the left navigation arrow in the blue header to return to the main page navigation. Then select the next available page to continue entering your application
This page is not applicable for Maintenance selection. Please continue to the next page.