Unity Provider Forms
EFT Authorization

Authorization Agreement for Electronic Fund Transfers (EFTs)


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Section 1: Provider Information





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Either Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)

Provider may list multiple NPI #’s if they share the Federal Tax ID listed above and Bank Account listed below.
A separate Implementation form needs to be completed for each unique bank account and Federal Tax ID.
Enter each NPI number on its own line.


Section 2: Provider Contact Information (Name of a contact in provider's office for handling EFT issues)








Section 3: Financial Institution Information





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You will receive an EFT for each Billing NPI


Section 4: Submission Information






The information contained within this form will be applied to all applicable contracts with Unity Health Plans Insurance Corporation, Quartz Health Solutions, Inc., Gundersen Health Plan, Inc., Gundersen Health Plan Minnesota, and Physicians Plus Insurance Corporation.



Authorized Signature


By checking this box, I authorize the provider to enroll with EFT with Quartz Health Solutions, Inc.,
Unity Health Plans Insurance Corporation, Gundersen Health Plan, Inc., Gundersen Health Plan Minnesota,
and Physicians Plus Insurance Corporation.
 



NOTE: EFT Payment will go into effect 7-10 business days from date of submission




* Indicates a required field.