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 Compliance Unit (MMAC) for processing, I understand
  • payment will be from Federal and State funds and that any falsification or concealment of material fact may be prosecuted under Federal and State laws;
  • the State of Missouri will initiate credit entries (deposits) and will initiate, if necessary, debit entries (withdrawals) or adjustments for any credit entries made in error to my account;
  • the State of Missouri may terminate my enrollment in direct deposit if the State is legally obligated to withhold part or all payments for any reason;
  • MMAC may terminate my enrollment if I no longer meet the eligibility requirements; and this document does not constitute an amendment or assignment of any nature whatsoever of any contract, purchase order or obligation that I may have with any agency of the State of Missouri.
Automated Clearing House (ACH) accounts only, wire transfer is not available.
All required information indicated by * must be completed.
A separate form must be submitted for each NPI/taxonomy code to be changed.

Please VERIFY your DEPOSITOR ACCOUNT NUMBER and ELECTRONIC ROUTING NUMBER with your financial institution.
NOTE: The check number should not be included in the depositor account number.         

SECTION I: PROVIDER INFORMATION
 Provider Name*
 
 Doing Business As Name (DBA)  
  Provider Address
  Street*   City*  State/Province*  Zip Code/Postal Code*
         -
SECTION II: PROVIDER IDENTIFIERS INFORMATION
 Provider Identifiers*
 Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)
 
  National Provider Identifier (NPI)
  
 Provider Taxonomy Code  
SECTION III: PROVIDER CONTACT INFORMATION
 Provider Contact Name *
 
 
 Telephone Number *
()  -
 Telephone Number Extension  
 Email Address  
SECTION IV: FINANCIAL INSTITUTION INFORMATION
 Financial Institution Name*
 
 
  Financial Institution Routing Number *
  Enter twice for validation
  
 

 Type of Account at Financial Institution*
  Checking
  Savings 
  Provider's Account Number with Financial Institution*
  Enter twice for validation
  
 
  Account Number Linkage to Provider Identifier (Select one and fill in the number)*
  Provider Tax Identification Number (TIN)   National Provider Identifier (NPI) 
 

 

SECTION V: SUBMISSION INFORMATION
 Reason for Submission*  New Enrollment     Change Enrollment     Cancel Enrollment   
 Include with Enrollment Submission*   Voided Check      Bank Letter   

  Authorized Signature *
  Electronic Signature of Person Submitting Enrollment
  
 Submission Date*  

This form complies with the CORE 380 EFT Enrollment Data Rule version 3.0.0 dated June 2012 mandated requirements.
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