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).

Provider Information

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

Provider Identifiers Information

e.g, Medicare, Medicaid, Fidelis Provider Group ID, etc.
Organization that issues and assigns the additional identifier requested on the form, e.g., Medicare, Medicaid

Provider Contact Information

Provider Agent Information (Optional)

e.g., Agent Services, Inc,
Name of provider’s authorized agent
Name of a contact in agent office for handling EFT issues
Title of contact in agent office for handling EFT issues

Financial Institution Information

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

Submission Information

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

Additional Information

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.

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