Provider EFT Request Form

Please note: Provider EFT payments are only available for BBA and CBA issued payments. Complete all fields below exactly as the information appears on your claim submissions.

Once submitted, a member of our Provider Maintenace team will reach out with instructions within 2-3 business days on how to complete your Zelis EPC Setup.

**There will be further action needed on your end to enable Zelis EPC, please keep an eye out for an email with further instructions**

Line of Business

This option should be selected only if the provider/practice submits claims to both the CBA and BBA lines of business. Please note that this will require two separate account setups with Zelis—one for each line of business. Additional instructions on completing each setup will be provided in the follow up email.

Provider/Practice Name

Tax ID

Group/Billing NPI

*Please note, we can only provision 1 NPI per TIN. If you have multiple Group NPI's, you will need to contact Zelis directly to setup smart routing. They can be reached at 1-877-828-8770 or by sending an email at CustomerService@ZelisPayments.com. Fees may apply*

Current Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Provider/Practice Email

example@example.com

You will be prompted to select a method of payment when completing your setup.