The form below is for Brokers only
. If you are a Provider or a representative for a Provider, please use the Provider EFT Form
Please make the corrections below and submit form again.
Broker 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 Broker Service Department at 1-877-259-8428. You can also email at
Please select the reason you are filling out this form.
The type of account the broker will use to receive EFT payments, e.g., Checking, Saving
Please select the type of account.
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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