Provider Electronic Funds Transfer (EFT) Enrollment Form

EMI Health is pleased to offer the convenience, savings and security of having your claims payments remitted electronically to your bank account (electronic funds transfer). This will save you the time and trouble of depositing checks, as well as allow you to receive payment more timely.

In order to enroll in this paperless method of payment, you must be receiving electronic remittance advices (835) from EMI Health through the Utah Health Information Network (UHIN) switch. You may contact UHIN by visiting their website at www.uhin.org, or phone at (801) 466-7705. Once you are actively accepting EDI 835s from EMI Health, fill out the information below to enroll.

If you have any questions, please contact our office at (801) 262-7476 or toll free at (800) 662-5850.

* Required Fields

In order to enroll in this paperless method of payment, you must be receiving electronic remittance advices (ERA or 835) from EMI Health through the Utah Health Information Network (UHIN) switch.

Provider Information

Provider Address

Provider Contact Informationtion

Financial Institution Information

Submission Information

I have read and agree to the terms and conditions: