You can find the medical and dental authorization agreement forms below. Use the appropriate form to enroll in EFT, change your EFT enrollment or update your ...

For EFT changes and ERA/EFT terminations (cancel), complete all applicable sections of the ERA and EFT authorization agreement and fax to 859-455-8650. You may ...

Complete a new authorization agreement form to make changes to an existing enrollment or to cancel an existing enrollment. Complete all parts of the form and ...

Use this form 1) to enroll or change in both ERA and EFT; 2) to change your ERA vendor only; or 3) to change your bank account.

ERA (Electronic Remittance Advice) Enrollment Form » This is a fillable form. Type your information into the form on your screen, or print the form and fill in ...

If you want to change your banking information, please complete the ERA/EFT enrollment form at: www.aetna.com/provider/data/ERA_EFT_Enrollment_Form.pdf.

If you want to cancel or change this authorization, you must contact Aetna at least three business days before a scheduled withdrawal. • You authorize Aetna to ...

Page 1 of 1. • Please fill in all appropriate information and sign where necessary. • Please print clearly using blue or black ink.

Email ERAForms@aetna.com to check the status of a new ERA/EFT enrollment request. • Email EDIHotline@aetna.com to check the status of an EFT change request.

New EFT enrollment or changes to existing EFT ... Please FAX completed form, voided check and/or bank letter to Aetna ERA Enrollment at 860-754-9122.