NAVITUS HEALTH SOLUTIONS, LLC

Electronic Funds Transfer (EFT) Authorization Request Enrollment Form

Navitus Health Solutions, LLC (Navitus) offers electronic payments to Participating Pharmacy(ies) that have entered into agreement by signing a Pharmacy Participation Agreement for participation in our network(s). This form is required by Navitus to initiate EFT services.

In order to sign up for this service, Navitus requires Participating Pharmacy to also accept and read 835 remittance advice files electronically and not currently be affiliated with and/or receive payment through a central-pay Pharmacy Services Administrative Organization (PSAO). If you are an affiliate of a PSAO and would like to change your payment to EFT, please contact your PSAO directly. At this time, Navitus cannot provide this service to Participating Pharmacies that receive paper remittance advices.

Initial Setup | Change to existing EFT Account | Cancel EFT

Pharmacy Information:

*Company Name:

Please provide at least one of the following two fields.

*Independent Pharmacy NCPDP Number:
*NCPDP Affiliation:

(Note: If affiliated with a PSAO, please contact them first to inquire about central pay options.)

Primary Pharmacy Contact:

*Name:

*Email:

*Department:

*Phone:

*Fax:

*Title:

Secondary Pharmacy Contact:

Name:

Email:

Department:

Phone:

Fax:

Title:

Requester Information:

*Company Name:

*Requester Printed Name:

*Requester Title:

Bank Information:

Attach a voided check or deposit slip to this form that includes the bank routing and account information. Only checking accounts can be accepted for Electronic Funds Transfer.

*Account number:

*Pharmacy Federal Tax Id:

*Account Name:

*Bank Routing Number:

*Bank Name:

*Bank Address:

Primary Bank Contact:

Name:

Email:

Department:

Phone:

Fax:

Title:

Secondary Bank Contact:

Name:

Email:

Department:

Phone:

Fax:

Title:

You must include a voided check or deposit slip along with this signed request form or Participating Pharmacy’s request for EFT will not be processed. Please note, in some instances the ACH routing number on your check differs from the ACH routing number by your bank in an official bank letter. In these cases, the ACH number identified in the bank letter is the number you should provide in Step 3.

Terms and Conditions

Individual/entity understands that by completing the ACH Authorization Form, the individual/entity is authorizing Navitus or its affiliates to deposit any sums owed into the account designated above.

Individual/entity understands that if a deposit is made into the account in error, the financial institution listed is authorized to return the erroneous payment to Navitus and to debit the account for an amount not to exceed the amount of the erroneous deposit.

Individual/entity agrees to notify the bank named above to permit deposits from Navitus company ID 3804360853.

Individual/ entity authorizes regularly scheduled payments to a banking account where recurring payments have been selected.

Individual/entity understands the payment will appear on your bank statement as an "ACH transaction."

Individual or entity agrees that no prior notification will be provided. Navitus may optionally provide prior notification including when the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

Individual/entity understands that this authorization will remain in effect until cancelled in writing, and Individual/entity agrees to notify Navitus in writing of any changes in the individual/entity account information or termination of this authorization at least 15 days prior to the next payment date.

If anticipated payment dates fall on a weekend or holiday, individual/entity understands that the payments may be executed on the next business day.

Individual/entity acknowledges that both parties and the origination of ACH transactions to this account must comply with the provisions of U.S. law, UCC Article 4A for electronic funds transfer, and the NACHA rules.

Individual/entity certifies that they are an authorized user of this bank account and will not dispute these scheduled transactions with the bank; so long as the transactions correspond to the terms indicated in this authorization form.

Individual/entity understands that Navitus may suspend or pause an ACH transaction in the event of a suspected fraud or irregularity with the depository account.

Individual/entity acknowledges that they will receive electronic remittance advices as 835 or PDF remittance separate from the ACH.

Please upload an image of type .png, .jpg, or .pdf.

Authorized Participating Pharmacy

*Name:

*Title:

Date: