WASHINGTON STATE HEALTH CARE AUTHORITY Authorization Agreement for Electronic Funds Transfer (EFT) PART I: DSHS Social Service Providers Only. Please Choose One: Applies to ALL Social Service locations with this tax ID Applies to ONLY the Social Service address listed. If you are not updating all of the Social Service locations under this tax ID you will need to submit an EFT form for each location. Note: This section must be filled out for the form to be complete. ALL providers. Please Choose One: New Enrollment Change Enrollment Cancel EFT Enrollment PART II: ORGANIZATION NAME NATIONAL PROVIDER IDENTIFIER (NPI) PHYSICAL STREET ADDRESS FEDERAL TAX ID OR EMPLOYER IDENTIFICATION NUMBER CITY PROVIDER NAME TITLE STATE/PROVINCE ZIP CODE + 4 TELEPHONE NUMBER (WITH AREA CODE) PART III: FINANCIAL INSTITUTION NAME FINANCIAL INSTITUTION ROUTING NUMBER checking savings account PROVIDER FINANCIAL INSTITUTION ACCOUNT NUMBER PART IV: Electronic Remittance Advice (HIPAA 835). This section does not apply to DSHS Social Service Providers. EDI/835 Delivered directly to provider (You will need a Trading Partner Agreement (TPA) ­ Please see instructions.) PART V: I hereby authorize and request Washington State to initiate credit entries to my account indicated above, and the depository named above is authorized to credit such account. If a reversal action is required, Washington State will notify the receiver of the error and give the reason for reversal. If any action taken by me, without adequate notification to Washington State, results in non-acceptance of the transfer by the designated financial institution, I understand that Washington State assumes no responsibility for processing supplemental payments until the funds are returned to Washington State by the financial institution. This authority will continue until Washington State has had a reasonable opportunity to act upon my written request to terminate EFT service or until Washington State determines that the required qualifications for enrollment are no longer being maintained. AUTHORIZATION (PRINT) TITLE (PRINT) AUTHORIZATION SIGNATURE DATE OF SUBMISSION PLEASE MAIL OR FAX FORM TO: HCA ­ MEDICAID PO BOX 45562 OLYMPIA, WA 98504-5562 FAX (360) 725-2144 HCA 12-002 (10/15) American LegalNet, Inc. www.FormsWorkFlow.com