Electronic Payment/Remittance Authorization Agreement
*
An asterisk denotes required information
Detailed instructions on how to complete this
form can be found at http://
providers.optimahealth.com/billing/Pages/eftera-authorizationagreement.aspx. If
you have any
questions, please contact
Optima Finance at EFT_ERA_INQUIRY@SENTARA.COM.
* Financial Institution Name
* Financial Institution
Routing Number
* Type of Account at
Financial Institution
* Provider’s Account Number
with Financial Institution
* Account Number Linkage to
Provider Identifier
(e.g., Preference for Aggregation of
Remittance Data )
FINANCIAL INSTITUTION INFORMATION
*
Provider Tax Identification Number (TIN)
ELECTRONIC REMITTANCE ADVICE INFORMATION
*
Preference for Aggregation
of Remittance Data
(e.g., Account Number Linkage to
Provider Identifier)
*
Provider Tax Identification Number (TIN)
* Method of Retrieval
YOU MUST HAVE AN OPTIMAHEALTH.COM USERNAME AND PASSWORD
If you do not have an Optimahealth.com user name and password, Providers may submit a
Provider Connection Enrollment Form which can be found at optimahealth.com (https://
www.formrouter.net/forms09@SNTRA/OptimaEnrollment.html)
Optimahealth.com Login ID:
Optimabehavioralhealth.com Login ID:
Access directly from Optima secure FTP Site
An Optima Health Finance representative will contact you to discuss specific requirements
Clearinghouse Name
Your clearinghouse must have a relationship with the Optima Health clearinghouse of choice: Misys-Payerpath.
Print from OptimaHealth.com
Clearinghouse
*
SUBMISSION INFORMATION
*
Reason for Submission
New Enrollment
Change Enrollment
Cancel Enrollment
PROVIDER INFORMATION
*
Provider Name
*
Provider Federal Tax Identification
Number (TIN) or Employer Identification
Number (EIN)
Please include TIN numbers for all
practice locations EFT applies to
*
National Provider Number (NPI)
*
Provider Contact Name
*
Telephone Number
*
Email Address
PROVIDER IDENTIFIERS INFORMATION
PROVIDER CONTACT INFORMATION
ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION
The EFT Authorization must be signed by an individual authorized by the provider or its agent to initiate, modify
or terminate an enrollment.
*
Submission Date
* Written Signature of person
Submitting Enrollment
*
Printed Name of Person
Submitting Enrollment
By your Authorized Signature and Printed Name, you are certifying that the account is drawn in the name of the
physician or individual Practitioner or the Legal Business name of the Provider or Agent. The Provider or Agent
has sole control of the account to which EFT deposits are made in accordance with all applicable Federal
regulations and instructions. All arrangements between the Financial Intuition and the said Provider or Supplier
are in accordance with all applicable Federal regulations and instructions with the effective date of the EFT
authorization. You must notify Optima Health in writing in regards to any changes in the account in sufficient time
to allow the contractor and the Financial Institution to act on the change.
*
Requested EFT Start/
Change/Cancel Date
*
Requested ERA
Effective Date
Voided Check
A voided check is attached to provide confirmation of Identification/Account Numbers.
Bank Letter
A letter on bank letterhead that formally certifies the account owners routing and accounting numbers
is attached
Optima Health Plan
Optima Behavioral
Checking Savings
Request Type
PLEASE NOTE THAT BY CHOOSING TO RECEIVE YOUR PAYMENTS ELECTRONICALLY, REMITS WILL ALSO BE DELIVERED
ELECTRONICALLY AND YOU MUST SELECT ONE OF THE OPTIONS BELOW. PAPER REMITS WILL CEASE.
Provider Numbers
Optima CORE Version 3.0.0 January 2020
