financial institutional telephone number / Services / bank changes / search existing data resources / bank / bank letterhead / financial institution/bank / /
Organization
Home office of Chain / Street Address Financial Institution’s City/Town Financial Institution / Chain Office / Name Financial Institution’s Street Address Financial Institution / DEPARTMENT OF HEALTH AND HUMAN SERVICES / State/Province Financial Institution’s Telephone Number Financial Institution / Internal Revenue Service / Telephone Number Financial Institution’s Contact Person Financial Institution / City/Town Financial Institution’s State/Province Financial Institution / Financial Institution / FINANCIAL INSTITUTION INFORMATION Financial Institution’s Name Financial Institution / MEDICARE / /
Position
Physician / contractor / Representative / designated contractor / authorized official / bank officer / authorized official of the chain home office / Authorized/Delegated Official Telephone Number Authorized/Delegated Official Title Authorized/Delegated Official E-mail Address Authorized/Delegated Official / Delegated Official / SIGNATURE LINE Authorized/Delegated Official / PRA Reports Clearance Officer / /
Electronic Funds Transfter EFT Authorization Agreement