Samaritan Health Plan Operations
Electronic Funds Transfer (EFT) and/or
Electronic Remittance Advice (ERA) Enrollment Form for Providers
View instructions for completing this form
* required field
Type of Submission
Select all that apply EFT Enrollment ERA Enrollment
Reason for submission:*  
Provider Information
Provider Name: *
Provider Identifiers Information
Provider Identifiers Select Type of Tax ID No.
Provider Federal Tax Identification Number (TIN)
or Employer Identification Number (EIN): *
 
National Provider Identifier (NPI): *  
Provider Contact Information
Provider Contact Name:*  
Telephone Number:*  
Email Address:
Submission Information
Authorized Signature
Electronic Signature of Person Submitting Enrollment:*  
Title of Person Submitting Enrollment:*