Electronic Funds Transfer (EFT) Enrollment QRG
Quick Reference Guide
NOTE: This information will be updated with the implementation of the new provider enrollment system, which is scheduled for April 2026. To stay informed about the transition effort, sign up for Florida Medicaid Health Care Alerts.
To comply with changes mandated by the Affordable Care Act, the Electronic Funds Transfer (EFT) Authorization Agreement was updated in February 2018 and is available on Enrollment Forms page. EFT authorization can also be completed online through the EFT Enrollment panel in the Secure Web Portal account.
Additionally, Section 1104 of the Affordable Care Act requires health plans to offer an EFT/ERA re-association number that allows providers to link an ERA to a specific EFT payment. It is optional for providers to receive the EFT/ERA re-association number. Providers interested in utilizing the benefits of the EFT/ERA re-association number should contact their financial institution to arrange for the delivery of the required data elements.
Completing the EFT Authorization Agreement
To access the paper EFT Authorization Agreement, Enrollment Forms page.
The form must be typed or printed legibly using blue or black ink. Fields marked with an asterisk (*) are required. Fields marked with a carat (^) are required if the information is available.
The chart below contains detailed information about each field on page 1 of the form:
| Field Name | Field Information |
| Provider Information | Complete legal name and mailing address of institution, corporate entity, practice, or individual provider (required). Enter D/B/A name, if applicable (optional). |
| Provider Identifiers: TIN/EIN/NPI | Enter Federal Tax-Identification Number or Employer Identification Number (required) and National Provider Identifier (required if available). |
| Other Identifiers: Florida Medicaid Provider Identification Number, Trading Partner ID | Enter Florida Medicaid Provider Identification Number OR Florida Medicaid Application Tracking Number (required) and Trading Partner ID (required if available). |
| Provider Contact Information | Enter provider name, telephone number, email address, and fax number for the person who should be contacted regarding EFT issues. Only the name and telephone number are required. An email address is required if available. |
| Financial Institution Information | Official name of the provider’s financial institution and street address associated with receiving depository financial institution name. The routing number is a nine-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited. Must be a valid ABA routing number. Enter the provider’s account number and select type of account (checking, savings, or lock box). All items in the financial institution information section are required. |
| Account Number Linkage to Provider Identifier | Select preference (TIN or NPI) for aggregation of data (required). Note: Selection MUST match preference submitted on ERA enrollment. |
| Submission Information | Select a reason for submission (new enrollment, change enrollment, or cancel enrollment). Form must include the authorized signature and printed name and title of the person submitting the enrollment. The form should be dated when signed. All items in the submission information section are required. |
Each person with signing privileges on the depository account should sign this form. If more than one authorized signer is required, complete the additional signature fields provided on page 2.
A voided check or a letter on bank letterhead must be attached to the form to certify the routing and account numbers.
Once the EFT Authorization Agreement is submitted, the request will be routed for account validation. Users should expect to receive paper checks via standard mail delivery for the next one to two payments. To ensure accurate and timely delivery of payments by check, users should verify the Pay To address on file with Florida Medicaid is accurate prior to submitting the EFT Authorization Agreement.
For processing, the completed form and attachments can be uploaded via the Secure Web Portal.
Additional Information
Center for Medicaid Services (CMS)
For more information regarding policies related to EFT, visit the CMS website at Operating Rules EFT and Remittance Advice.
Additional Resources
Florida Medicaid Contact Information Sheet
Support
Training
AHCA Adopted Rules
AHCA Medicaid Forms
Provider Enrollment Policy incorporated by reference in Rule 59G-1.060, F.A.C.
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