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.

Pharmacy Information:

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

Primary Pharmacy Contact:

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Secondary Pharmacy Contact:









Requester Information:

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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.
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Primary Bank Contact:









Secondary Bank Contact:







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.


This form must be signed by the Participating Pharmacy’s authorized bank account holder. Participating Pharmacy authorized signatory hereby authorizes Navitus Health Solutions to initiate deposits (credits) payments to the financial institution indicated above. If necessary, Navitus Health Solutions may process withdrawal adjustments to this account in the event of overpayment. This authority is to remain in full force and effect until revoked by giving a 30 day written notice to Navitus Health Solutions.


Several reasons for revoking authorization are as follows:

  • Navitus Health Solutions receives a 30 day written notice of cancellation
  • The Participating Pharmacy’s payment status with Navitus changes such that payments are no longer to be made directly to the Participating Pharmacy, but instead to a third party. Navitus Health Solutions receives monthly files from NCPDP. If Participating Pharmacy becomes affiliated with a PSAO/TPA that centrally pays its pharmacies this agreement will be terminated.
  • Navitus Health Solutions may cease providing EFT services at any time upon notice to the Participating Pharmacy.

Navitus requires Participating Pharmacy to instruct its bank to process EFT for Participating Pharmacy using the funds transfer system. Participating Pharmacy acknowledges that they will receive remittance advices in the form of an ASC X12 835 electronic file separate from the EFT. Participating Pharmacy acknowledges that by receiving the remittance advice does not constitute that the EFT been received by Participating Pharmacy’s bank. Therefore, Navitus Health Solutions will not be in breach of the Participating Pharmacy Agreement or this EFT form or suffer any other penalty with respect to an EFT that was initiated accurately and timely by Navitus Health Solutions to the extent that the funds transferring system or Participating Pharmacy’s bank incurs a failure/rejection or is delayed.


By signing below the individual authorizing the EFT on behalf of Participating Pharmacy hereby certifies that:

  1. Participating Pharmacy hereby authorizes the EFT transactions describe herein
  2. All information contained within this request is true and accurate in all respects
  3. The individual has actual authority to execute this request on behalf of Participating Pharmacy



Authorized Participating Pharmacy


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