Prior to mailing the EFT Authorization Form (that follows on the next page) ....
Group number need only complete a single enrollment form for the Group NPI.
for the purpose of picking up my Test Report Form for the test taken on ... A letter
of authorization to include: authorize full name, candidate number, test date & ...
Mail or Drop in Slot: Village of Bannockburn. Attn: Water Billing. 2275 Telegraph Road. Bannockburn, IL 60015. 2-2014 -
above named camper, to authorize on my behalf all medical and other ... projects (including promotion, marketing and soc
reimbursement of any willful destruction to site and/or equipment, including graffiti, incurred as a result of their chi
Service Address (property where utility services are occurring). Water account number. Daytime Phone Number. Email. For
AUTOMATIC BANK PAYMENT AGREEMENT AUTHORIZATION â UTILITY ... Email. For a checking account, please attach a voided che
PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM. Plan/
Medical Group Name: Care1st Health Plan. Plan/Medical Group Phone#: (877)
792- ...
Yes! I would like to set up an automatic debit for my Google AdWords bill to my credit card account. The entire amount o
Care1st Internal Use re sr. HEALTH PLAN DOE;. Medication Prior Authorization
Form IPA: LOB: Pharmacy Department Fax: (323) 889-6254 or (866) 712-2 731.
hereby authorize this card to be used for the deposit and/or. Printed Name final payment for Invoice(s) ______. ... Secu
Please complete the top half of this form and fax to A & N with payment instructions. A confirmation of the final ch
TennCare Pharmacy Program, c/o Magellan Health Services, 1st Floor South, ... If
the following information is not complete, correct, or legible, the PA process ...
500 Esplanade Drive, Suite 400, Oxnard, California 93036 (805) 485-3193 Fax (805) 988-9832 PROPERTY REMOVAL AUTHORIZATION FORM Tenant Name Date _____
HIPAA Privacy Authorization Form. Authorization for Use or Disclosure of
Protected Health Information. (Required by the Health Insurance Portability and ...
I, the designated cardholder of the above listed card, authorize MicroAge to charge the amount of $______ to the above l
Aug 29, 2017 - Typed or digital signature is permitted. Approved by Local Emergency Manager: Signature: ... Signature: D
CREDIT CARD AUTHORIZATION FORM. Card Holder Information. Card Type (check one):. MasterCard. American Express. Name (as
Checking Account #:. IPC Signature: For Office Use Only: Initials. Information has been entered. Date: Date. Phone #:. S
7) Authorized Amount $: ______. 8) Authorized Gratuity (if applicable):$ ______.
9) Name on Reservation (if applicable): PLEASE READ AND SIGN: This fax ...
Please complete and fax this form to Caremark at 888-836-0730 to request a
Drug Specific Prior ... fax the Drug Specific Prior Authorization Request Form to
us, we will review it and notify you and ... Last Name, First Name (PLEASE PRINT
).
We need a new system for helping people on campuses find their reports, so we are designating two offices that will rece
Accessible 24/7. • Authorization letters will not get lost in the mail or in ... Only
approval letters are electronic, while adverse ... Submit customer service
inquiries.
A signed letter on your bank's letterhead verifying your account information must
be ... person signing this Electronic Payment Authorization form is authorized to ...
Southwest Florida Water Management District ELECTRONIC PAYMENT AUTHORIZATION Please complete this form and return to: Finance Administrative Supervisor Southwest Florida Water Management District 2379 Broad Street Brooksville, Florida 34604-6899 352-796-7211, Extension 4121
PAYEE INFORMATION:
EFT FINANCIAL INSTITUTION INFORMATION:
Federal Employer Identification Number (FEIN):
Bank's ABA (routing) Number:
Vendor Name and Address: Bank Account Number:
Bank Account Type: Checking ____ Contact Person: Phone Number:
Savings ____
Account Name:____________________________________________ Name and complete address of Bank or financial institution:
FAX Number: E-mail Address:
These payment instructions are authorized, and the terms and conditions for Electronic Funds Transfer payments on the reverse of this form are accepted by:
Bank Phone Number: Type of file format required by Bank or financial institution, if applicable:
A signed letter on your bank's letterhead verifying your account information must be attached to this request. The letter also must verify that the person signing this Electronic Payment Authorization form is authorized to sign on the account listed. A sample format letter is provided to assist your bank with preparation of this letter. ORIGINALS of both this form and the bank's letter must be returned to the address above. NO FAXES WILL BE ACCEPTED. VENDOR
14.00-017 (Rev 08/07)
Southwest Florida Water Management District ELECTRONIC PAYMENT AUTHORIZATION
INSTRUCTIONS This form is for Vendors of the Southwest Florida Water Management District (District) who wish to request payments by electronic funds transfer for goods or services provided to the District. • • • • •
All information provided on this form must be complete. It is important that the address and phone number for your Bank or financial institution be included. The accuracy of the information provided regarding your financial institution's routing number and your account number is critical to ensure that funds are routed correctly. Please confirm these numbers with your financial institution's operations manager. Your financial institution must prepare a verification letter on their letterhead to be attached to this request. Please provide the "Sample Letter for Transmittal" to your financial institution for reference in creating this letter. Please provide the e-mail address for receipt of the EFT remittance notification.
TERMS AND CONDITIONS This authorization will remain in effect until withdrawn in writing with sufficient notice to the District to allow adequate time to effect termination. The District will not be responsible for any loss that may arise solely by reason of error, mistake or fraud regarding information provided on this Electronic Payment Authorization form. Only an authorized representative of the payee may make changes to the information on this form in writing. Changes to account information will cause the original authorization to be immediately inactivated. This form authorizes the District to initiate credit entries and, if necessary, a reversing entry in accordance with NACHA rules Article II, Sections 2.4 and 2.5 in order to correct a credit entry made in error. Such entry is not made without prior notice to the payee and only if the entire amount of the payment is not due to the payee. Such reversing entry can be initiated only within five (5) banking days of the deposit effective date.
VENDOR
14.00-017 (Rev 08/07)
Sample Letter for transmittal from bank personnel to Southwest Florida Water Management District, Finance Administrative Supervisor. Completed Letter Must Be Attached to Electronic Payment Authorization Form
MUST BE ON FINANCIAL INSTITUTION'S LETTERHEAD
(Date)
Finance Administrative Supervisor Southwest Florida Water Management District 2379 Broad Street Brooksville, Florida 34604-6899 To Whom It May Concern: I have verified that the account and transit-routing numbers provided on the attached Southwest Florida Water Management District Electronic Payment Authorization form for (insert name of payee from authorization form) are correct. I have further verified that (insert name of person whose signature appears on the authorization form) is authorized to sign on the account provided and that this is (his/her) signature. If you have any questions, please call me at (telephone number) . Sincerely,
(Signature of Bank Officer) (Printed Name of Bank Officer) (Title of Bank Officer)
