Telephone Extension. Contact person’s telephone extension, if applicable. Email Address: Electronic mail address at which Medi-Cal Rx staff may reach the contact person. Fax Number: Number at which the provider can be sent facsimiles, with no dashes or spaces (e.g., 8888888888). Financial Institution Information Financial Institution Name: Official name of the provider’s financial institution. Address fields: Address (number, street name, city, state, and ZIP Code) associated with the receiving depository financial institution.
Appears in 1 contract
Sources: Eft Authorization Agreement
Telephone Extension. Contact person’s telephone extension, if applicable. Email Address: Electronic mail address at which Medi-Cal Rx staff may reach the contact person. Fax Number: Number at which the provider can be sent facsimiles, with no dashes or spaces (e.g., 8888888888). Financial Institution Information Financial Institution Name: Official name of the provider’s financial institution. Address fields: Address (number, street name, city, state, and ZIP Code) associated with the receiving depository financial institution.
Appears in 1 contract
Sources: Electronic Remittance Advice (Era) Authorization Agreement