Fillable BEFTb Enrollment bFormb - CountyCare

Description
Electronic Funds Transfer (EFT) Authorization Agreement Provider Name Doing Business As (DBA) Provider Street Address Provider City Provider State/Province Provider ZIP Code/Postal Code Provider Tax Identifier (TIN or Employer Identifier (EIN) National Provider Identifier (NPI) Assigning Authority Medicaid Trading Partner ID Provider Contact Name Provider EMail Address Provider Phone Number Provider Fax Number...
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