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

  • For EFT specific questions: Please contact HPSM Provider Services at PSinquiries@hpsm.org
  • For ERA specific questions: Please contact HPSM directly at (650) 616-2106
  • For both EFT/ERA questions: Please contact HPSM Provider Services at PSinquiries@hpsm.org
  • HPSM can ONLY update EFT Banking information for your Provider Group Billing NPI. Please double check your group NPI and Tax ID prior to submission for faster processing time.
  • HPSM can ONLY issue ERAs through a direct provider connection or one of our contracted clearinghouses (Office Ally, Change Healthcare, Trizetto/Gateway EDI), please utilize one of these options for faster processing time.

Additional NPIs can be added later