EFT Enrollment Data
Providers currently set up for electronic remits are eligible to receive electronic fund transfers (EFT). To enroll or make changes to an EFT account, complete and submit this form. Forms must be received by the 15th of the month to begin depositing payment directly to your account by EFT the following month. A confirmation letter will be sent once your request is processed.
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Reason for Submission

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Provider Information

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Financial Institution Information

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Type of Account at Financial Institution
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I HEREBY CERTIFY THAT I AM AN AUTHORIZED SIGNER ON BEHALF OF THE ABOVE NAMED PROVIDER. I ALSO CERTIFY THAT BCBSND IS AUTHORIZED TO ENTER TRANSACTIONS INTO THE ABOVE ACCOUNT. THIS AUTHORIZATION IS TO REMAIN IN EFFECT UNTIL A 30-DAY WRITTEN NOTICE IS GIVEN TO BCBSND TO CEASE THESE TRANSACTIONS.

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Provider Contact Information

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Provider Networks
Contact Information:

Fax: (701) 282-1910

Mailing Address: 

BCBSND
Attn: Provider Networks
4510 13th Ave S
Fargo, ND 58121

Email: prov.net@bcbsnd.com

Phone: 800-756-2749

 

Instructions for completing
EFT Enrollment Data