OR ITS / ACCOUNT AT FINANCIAL INSTITUTION / FINANCIAL INSTITUTION INFORMATION Financial Institution Name* Financial Institution Routing Number* Provider’s Account Number With Financial Institution / Missouri Medicaid Audit and Compliance Unit / MISSOURI DEPARTMENT OF SOCIAL SERVICES / FINANCIAL INSTITUTION ROUTING NUMBER* PROVIDER’S ACCOUNT NUMBER WITH FINANCIAL INSTITUTION* PROVIDER’S ACCOUNT NUMBER WITH FINANCIAL INSTITUTION / / /
MISSOURI DEPARTMENT OF SOCIAL SERVICES (DSS) MISSOURI MEDICAID AUDIT AND COMPLIANCE (MMAC) Electronic Funds Transfer (EFT) Authorization Agreement By completing and submitting this form to the Missouri Medicaid Audit and