Electronic Funds Transfer (EFT) Authorization Form

This form must be completed by providers to receive claim payments via an Electronic Funds Transfer (EFT). This form must be completed upon initial enrollment, if you change your financial institution, or if there is a change in your financial account status.

• Electronic Funds Transfer (EFT) Authorization Form (470-4202) Instructions

Provider Information

Enter complete legal name of institution, corporate entity, practice or individual provider

The number and street name where the provider or organization can be found

City associated with provider address field



Enter a Federal Tax Identification Number, also known as an Employer Identification Number

10 character National Provider Identifier (NPI)
Provider Contact Information (Contact information of the person completing this form)


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Financial Institution Information

Official name of the financial institution

The number and street name where the financial institution can be found

City associated with provider address field.



A 9-digit identifier of the financial institution where the provider maintains an account to which payments are deposited


Provider's account number with financial institution

Select Provider Preference for grouping (bulking) claim payments.
Reason for Submission



Please type your full name

By signing this document I authorize the Iowa Medicaid Program to apply my Medicaid payments to the account specified above. I understand that payment is made from State and Federal funds and that any falsification or concealment of a material fact may be prosecuted under State and Federal laws. I understand that my electronic signature certifies acceptance of the provider certification on the claim form and/or Provider Agreement. I also certify that I am legally authorized to make this certification, and that I may be prosecuted under applicable State or Federal laws for any false statements or documents submitted.


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