Electronic Funds Transfer (EFT) Attestation

I hereby certify that the checking OR savings account indicated on this application is under my direct control and access; therefore, I authorize DHHS and its legally authorized fiscal agents(s), contractors, or vendors, their successors and assigns, to initiate, change or cancel payment to the checking or savings account as indicated on this application. I understand that Medicaid enrolled providers are required to enroll in EFT for claims payment and consent to the Department and its legally authorized fiscal agent(s), contractors, or vendors, their successors and assigns, to make claims payments to the checking or savings account indicated on this application. I consent to the release and communication of the checking or savings account information on this application to DHHS and its legally authorized agents, contractors, or vendors, their successors and assigns for the purposes of DHHS health plan participation and/or program operations. This authority is to remain in full force and effect until DHHS's legally authorized fiscal agent, its successors and assigns has received written notification, from either myself or a verifiable Officer of the Agency, of the account's termination in such time and in such a manner as to afford DHHS and its legally authorized agents, contractors, or vendors, their successors and assigns a reasonable opportunity to act upon it.