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    ECHO Health EFT Bank Update Form

    Uploaded by

    RON THOMTON
    This document is a bank account update form for healthcare providers to change their bank account information for receiving ACH payments from ECHO Health Inc. It requests information such as the provider name, address, tax ID, existing bank account details, new bank account details, and requires a signature. It provides instructions on how to fill out and submit the form.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    ECHO Health EFT Bank Update Form

    Uploaded by

    RON THOMTON
    48 views1 page
    This document is a bank account update form for healthcare providers to change their bank account information for receiving ACH payments from ECHO Health Inc. It requests information such as the provider name, address, tax ID, existing bank account details, new bank account details, and requires a signature. It provides instructions on how to fill out and submit the form.

    Original Title

    ECHO-Health-EFT-Bank-Update-Form

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    This document is a bank account update form for healthcare providers to change their bank account information for receiving ACH payments from ECHO Health Inc. It requests information such as the provider name, address, tax ID, existing bank account details, new bank account details, and requires a signature. It provides instructions on how to fill out and submit the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    48 views1 page

    ECHO Health EFT Bank Update Form

    Uploaded by

    RON THOMTON
    This document is a bank account update form for healthcare providers to change their bank account information for receiving ACH payments from ECHO Health Inc. It requests information such as the provider name, address, tax ID, existing bank account details, new bank account details, and requires a signature. It provides instructions on how to fill out and submit the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Bank Account Update Form

    Healthcare Provider

    INSTRUCTIONS: This form should only be used if you have an existing EFT/ERA enrollment with ECHO Health, Inc. and would like to
    change the bank account set up to receive ACH payments.
    1. This is a fillable form. Type in your information on your screen and print the form, OR print the form and fill in your information. Note:
    * Required
    information; ** Required information for one section OR the other in which it appears.
    2. Manually sign the form. Return the completed form to ECHO Health, Inc. by email (secure recommended), fax or regular mail.

    Email to: edi@EchoHealthinc.com Mail to: ECHO Health, Inc.


    Fax to: 440.835.5656
    810 Sharon Drive
    Westlake, OH 44145

    HEALTHCARE SERVICE PROVIDER INFORMATION


    Name* ___________________________________________________________________________________________________
    Billing Address (number, street)* ________________________________________________________________________________
    (city, state, zip code)* _____________________________________________________________________________
    Tax ID Number (TIN)* _________________________ Email* _________________________________________________________

    SECURITY
    For security purposes, please provide an ECHO® Draft Number and matching ECHO Draft Amount to validate against your Tax ID. The ECHO
    Draft Number is a 9-digit number starting with "2" or a 10-digit number starting with "1".

    ECHO Draft Number* ___________________________________ ECHO Draft Amount* $ ________________________

    AUTHORIZATION TERMS & CONDITIONS


    Healthcare Service Provider hereby authorizes ECHO Health, Inc., hereinafter called “ECHO”, to initiate credit entries for approved benefit
    plan payments to said Healthcare Service Provider’s account, identified hereinafter as “Depository”.

    I also understand that this authority is to remain in full force and effect until ECHO has received written notification from Healthcare Service
    Provider of its termination in such time and in such manner as to afford ECHO a reasonable opportunity to act on it, which in any way shall
    not be less than ten banking days after receipt.

    Bank Account to be Updated (Depository) Information New BANK ACCOUNT (Depository) Information
    Required: Enter information for the existing account you wish Required: Enter information for the new account you wish to
    to replace. set up.

    BANK NAME**_______________________________________ BANK NAME** _______________________________________

    ADDRESS** _________________________________________ ADDRESS** _________________________________________


    (number & street) (number & street)

    _________________________________________ _________________________________________
    (city, state, zip code) (city, state, zip code)

    TRANSIT/ABA NO.** ___________________________________ TRANSIT/ABA NO.** ___________________________________

    ACCOUNT NO.** _____________________________________ ACCOUNT NO.** _____________________________________

    ACCOUNT TYPE** ____________________________________


    (checking or savings)

    APPROVAL (By person holding Tax ID shown on this form – please fill in all information completely).

    Executed By (print name)* __________________________________________ Title* ___________________________________

    Phone* ______________________________ Email* ___________________________________________________________

    Date* _________________________ Executed By (signature)* __________________________________________________


    (mm/dd/yyyy)

    CLEAR PRINT

    ECHO Health, Inc. || 810 Sharon Drive || Westlake, Ohio 44145 || ph: 440.835.3511 || fax: 440.835.5656 || www.EchoHealthinc.com
    Bank Account Update Form 120222 V1E

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