EFT ENROLLMENT

Please complete the form below and click "Submit" if you would like to enroll in Electronic Funds Transfer. Please use the "Reason for Submission" field to indicate whether this is a New Enrollment or a Change to Existing Enrollment. For details about any particular field in the form below, please hover over the required field for a brief description. For more information, please call the Fidelis Provider Call Center at 1-888-FIDELIS (1-888-343-3547).

Reason For Submission

Provider Information

Provider Name Complete legal name of institution, corporate entity, practice or individual provider

Provider Street Address Address Line 2

County

City

State

Zip Code

Provider Identifiers Information

Provider Group TIN or EIN Provider Group NPI

Other Identifiers e.g, Medicare, Medicaid, Fidelis Provider Group ID, etc.

Assigning Authority Organization that issues and assigns the additional identifier requested on the form, e.g., Medicare, Medicaid

Provider License Number

License Issuer

Provider Contact Information

Provider Contact Name

Title

Phone Number

Extension

Fax Number

Email Address

Provider Agent Information (Optional)

Agency Name e.g., Agent Services, Inc,

Provider Agent Name Name of provider’s authorized agent

Agent Street Address

City

State

Zip Code

Provider Agent Contact Name Name of a contact in agent office for handling EFT issues

Title Title of contact in agent office for handling EFT issues

Phone Number

Extension

Email Address

Financial Institution Information

Financial Institution Name

Financial Institution Street Address Address Line 2

City

State

Zip Code

Financial Institution Telephone Number

Type of Account The type of account the provider will use to receive EFT payments, e.g., Checking, Saving

Routing Number

Account Number

Provider Identifier Linked to Account

Submission Information

Attach Voided Check A voided check is attached to provide confirmation of Identification/Account Numbers. Browse to upload voided check image in these formats: gif, jpg, jpeg, doc, docx, or pdf

EFT Effective Date Date must be in the future and in mm/dd/yyyy (i.e. 4/30/2024) format

Additional Information

Participation Status

Participating

Non-Participating

Fidelis Legal Notice

This FIDELIS CARE system is solely for use by authorized users or customers conducting FIDELIS CARE business. To protect the system from unauthorized use and to ensure that the system is functioning properly, individuals using this computer system are subject to having all of their activities on this system monitored and recorded by FIDELIS CARE system personnel. By using this system you expressly consent to such monitoring.

Moreover, if such monitoring reveals evidence of possible abuse or illegal activity, FIDELIS CARE is authorized to take whatever legal action it deems necessary, including providing the results of such monitoring to appropriate regulatory and law enforcement officials. Your unauthorized use of this system may subject you to civil and potential criminal penalties. Evidence of unauthorized use collected during monitoring may be used as FIDELIS CARE deems necessary.

I confirm this information is accurate and complete. I understand inaccurate information may delay or prohibit payments.