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Electronic Funds Transfer Authorization Agreement Form Instructions

Instructions to Set Up an Account

To successfully authorize the use of Electronic Funds Transfer for the Depositing of Escrow Funds into a Checking account, the following steps must be completed. 

1.       Log on EI Billing and go to:

Ø  Maintenance

Ø  Provider Profile

Ø  Escrow Payment Information

2.       Select “Request New EFT Account Setup”

3.       Input the following financial information:

a.       Routing Number

b.      Confirm Routing Number

c.       Account Number

d.      Confirm Account Number

§  Both the routing and account numbers can be found at the bottom of your check

e.      Account description will be populated automatically

f.        Email Address,  please enter email address for the person who is responsible for account information this may or may not be the email address currently in EI Billing

g.       Confirm Email Address

4.       Select “Generate Form”, which will bring you to a pre-filled PDF form

a.       Check box, “Check here if requesting initial setup of EFT Deposit”

b.      Confirm that the information on the pre-filled PDF form is correct

c.       Print the form and close the PDF

d.      If correct than select “Yes the form printed correctly”

e.      Once submitted you will not be allowed to re-print

5.       Select “Submit” – request will go to the Escrow Accounting Department at PCG

6.       Complete Section IV, Provider Signature and Authorization

a.       The printed copy of the form must be signed by the Provider or designated practice or       business representative, and include the date signed

b.      If the account is a joint account, both signatures must be provided

7.       Send the signed Agreement Form and one of the following banking documents to PCG

a.       For Checking Accounts, with checks:  An original blank check from the checking account to which the funds are to be transferred from PCG. The word “VOID” must be written across the face of the check. The check must contain the name and address of the Provider or Provider organization.

b.      Deposit only checking accounts, do not have checks:   Accepted with the following documentation:

                                                i.       An original letter from the bank officer.  The letter must be on bank letterhead, signed by bank officer, notarized by a notary public, and include the following:

1.       The Bank’s name and address

2.        Routing number

3.       The type of account

4.       Account number

5.       The account owner’s name

6.       Owner’s address

7.       Owner’s tax ID

8.       The Agreement Form and supporting banking documents can be sent to PCG via one of the following:

a.       Secure Fax: 1-518-338-1580

Attention:  Escrow Accounting

b.      Email: 

Attention:  EFT Setup

* EFT Authorization Agreement Forms that do not comply with these instructions will be rejected

What to Expect

·         Allow a minimum of 4-6 weeks for your request to be processed.

·         During the process period a test transaction for 0 dollars will be transferred to the Provider’s account.

·         Provider will be notified that the test transaction has passed or failed.

·         If the transaction fails, the Provider will need to start the enrollment process again.

·         Due to normal banking procedures, the funds may not become available in the Provider’s chosen account for up to 48 hours from the initial transfer. Contact your banking institution with questions about the availability of funds.

Instructions to Withdraw an EFT request

Provider may withdraw their request for an EFT account set-up prior to the EFT payment being approved by the SFA.

1.       Log on EI Billing and go to:

Ø  Maintenance

Ø  Provider Profile

Ø  Escrow Payment Information

2.       Select “Request Cancellation”

*Please note that if an EFT has already been approved by the SFA and you wish to generate a paper check follow the Instructions to Cancel EFT Transactions.

Instructions to Change Banking Information

1.       Follow the instructions above for setting up an account

2.       In addition:

o   On Agreement Form check box for “Check here if requesting change from current EFT Deposit”

o   Send a letter indicating changes to your account with the new authorization form. The letter must be on company letterhead and include any Provider number(s) (TIN and NPI), the new account number and/or routing number, and a brief explanation for the change. The letter must be signed.

*Payments will continue in your current account until the new account has been approved


Instructions to Cancel EFT Transactions

1.       Log on EI Billing and go to:

Ø  Maintenance

Ø  Provider Profile

Ø  Escrow Payment Information

2.       Select “Request Cancellation”

3.       Select “Generate Cancellation Form”

4.       Print form and Complete Section III Provider Signature and Authorization and send to PCG via secure fax or email (see step 8 under “Instructions to Set Up an Account)

* Allow 4-6 weeks to transition to a paper check

Article ID: 250, Created On: 4/14/2015, Modified: 3/28/2023

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