• Confronting issues of missing checks, let’s get enrolled and get easy payments direct into your bank accounts.
  • For more info, please contact our enrollment team at credentialing@eclaimsolution.com or +1 713-234-6016

EFT Enrollment Intake Form

Financial Institution Information

Financial Institution Address

  • Void Check or Original Bank Letter (Letter must be attested)
  • IRS EIN Assignment Letter
  • W9