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).
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