Unity Provider Forms
EFT Authorization

Authorization Agreement for Electronic Fund Transfers (EFTs)


Need Help Filling Out This Form?


Section 1: Provider Information





-

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





-




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. f/k/a SPWI TPA, Inc. d/b/a Quartz, and Gundersen Health Plan, Inc.



Authorized Signature


By checking this box, I authorize the provider to enroll with EFT with Unity Health Plans
Insurance Corporation and/or SPWI TPA, Inc., d/b/a Quartz.
 



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