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that by using Regence Electronic Funds Transfer, we will no longer receive printed voucher summaries.
I (we) certify that I am a duly authorized signer of the above designated bank account and as such hereby authorize Regence, to initiate credit entries and, if and only to the degree necessary for any credit entries initiated in, debit entries to my (our) account indicated above and authorize the depository indicated above, hereinafter called DEPOSITORY, to credit and/or debit the same to such account. This authorization is to remain in full force and effective until Regence has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Regence and DEPOSITORY a reasonable opportunity to act on it. In the event Regence finds it necessary to initiate a correcting debit or credit entry, the account holder will be notified in advance. Modifications to this agreement will result in an automatic denial of your request to establish automatic deposit.
You must fax or email a copy of a voided check or bank letter to support this request.
Email notification for Electronic Remittance Advice (ERA), EFT Deposit, and Pended Claims Summary is available.
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