Electronic Fund Transfer (EFT)
I hereby authorize Cook Children’s Health Plan to initiate credit entries to deposit my vendor payments at the
financial institution named below. If funds to which I am not entitled are deposited to my account, I also
authorize Cook Children’s Health Plan to make the necessary debit entries and adjustments to correct the error
without additional signatures by my authorized representative.
I authorize Cook Children’s Health Plan to initiate a pre-note before the first vendor payment is deposited.
This agreement will remain in effect until Cook Children’s Health Plan receives a written notice of cancellation
from me or my financial institution.
FOR ACCOUNT VERIFICATION PLEASE PROVIDE A VOIDED CHECK OR A LETTER OF INSTRUCTION
FROM YOUR FINANCIAL INSTITUTION.
Authorized Signature _______________________________________________
Printed Name _______________________________________________
Financial Institution Name
ACH Routing Number
Tax ID Number
Provider Contact Name
Provider Contact E-Mail
Provider Contact Phone Number
RETURN FORM TO:
Cook Children’s Health Plan
P. O. Box 2488
Fort Worth, TX 76113-2488
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