Electronic Funds Transfer (EFT) Authorization Agreement

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Provider Information

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Provider Identifiers Information

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Provider Contact Information

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Financial Institution Information

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Submission Information

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Maximum total file size: 20MB

Authorized Signature

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Authorization

By signing above, I hereby authorize Hawaii Medical Service Association, hereinafter called the COMPANY, to initiate credit entries, and initiate adjustments for any credit entries made in error to the account indicated above. I hereby authorize the financial institution/bank named above, hereinafter called the DEPOSITORY, to credit and/or debit the same to such account. I certify that the account is used solely for business purposes. This authorization agreement will be effective within ten (10) days of acceptance by the Depository and is to remain in full force and effect until the COMPANY has received written notification from me of its termination in such time and such manner as to afford the COMPANY and the DEPOSITORY a reasonable opportunity to act on it. The COMPANY will continue to send the direct deposits to the DEPOSITORY indicated above until notified by me that I wish to change the DEPOSITORY receiving the direct deposit. If my DEPOSITORY information changes, I agree to submit to the COMPANY an updated EFT Authorization Agreement.


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