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Electronic Funds Transfer

Use this form to request, make changes to or cancel payments via electronic funds transfer (EFT). Fax the completed form with a voided check or bank letter to 1-844-951-0689.

Note: Do not fax medical documentation or claims containing patient information to the HNFS Finance Department.

 

  • Created: Jun 16, 2014
  • Modified: Aug 28, 2020
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