EFT/ERA Authorization Form

Provider Information

Provider Name

Address

Zip

City

State

Fax Number

Email Address

Additional Provider Information

Doing Business As (DBA)

Contact Name

Contact Email

Contact Direct Line

Additional Email to Notify

Additional Email to Notify 2

EFT/ERA

Are you signing up for?

Intended Effective Date

Multiple NPI Numbers

Bank Validation

Please upload a voided check and/or bank letter

Valid file types: PDF, TIFF, TIF, PNG.
Maximum file size 20 MB

Authorized Account Representative and Signature

Health Plan of San Mateo (HPSM) is committed to timely, accurate, and efficient payment to providers and has a policy to use EFT and ERA as the primary method of payment and remittance advice communication. This EFT/ERA Authorization Form is the consent of your organization to receive payments through EFT and access remittance advice information either through a secure HPSM portal or through a billing clearinghouse via 835 file transaction.

This EFT/ERA Authorization Form will remain in effect unless changed or cancelled by your organization using this EFT/ERA Form.

Name of Authorized Representative Submitting Form

Title of Authorized Representative Submitting Form

Electronic Funds Transfer & Electronic Remittance Advice (EFT/ERA) Authorization Form

Provider Information

Provider Information

Additional Provider Information

EFT/ERA

Financial Institution Information

Clearinghouse Information

Multiple NPI Numbers

Bank Validation

Authorized Account Representative and Signature