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AAA
Дом | Fidelis CareEFT Form Brokers
The form below is for Brokers only. If you are a Provider or a representative for a Provider, please use the Provider EFT Form.
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Please make the corrections below and submit form again.

Broker EFT Enrollment

Please complete the form below and click "Submit" if you would like to enroll in Electronic Funds Transfer. Please use the "Reason for Submission" field to indicate whether this is a New Enrollment or a Change to Existing Enrollment. For details about any particular field in the form below, please hover over the required field for a brief description. For more information, please call the Fidelis Broker Service Department at 1-877-259-8428. You can also email at brokerservices@fideliscare.org.


Please select the reason you are filling out this form.

Broker Information

Complete legal name of institution, corporate entity, practice or individual broker Please enter a name, per the description above.
Please enter the street address of the broker.
Please enter the city of the broker.
Please select the state of the broker.
Please enter the zip code of the broker.

Broker Identifier Information

Your Fidelis Care Broker ID (12 numbers) Please enter the ID of the broker.
Please enter the TIN, EIN, or SSN of the broker.

Broker Contact Information

Please enter the first and last name of the broker contact.
Please enter the job title of the broker contact.
Please enter the phone number of the broker contact.
Please enter the email address of the broker contact (ex: mail@mail.com).

Financial Institution Information

Please enter the name of the financial institution commission checks should be sent to.
Please enter the street address of the financial institution.
Please enter the city of the financial institution.
Please select the state of the finanical institution.
Please enter the zip code of the financial institution.
Please enter the phone number of the financial institution.
Please enter the name of the account holder at the financial institution.
The type of account the broker will use to receive EFT payments, e.g., Checking, Saving Please select the type of account.
Please enter the routing number for the financial institution.
Please enter the account number.

Submission Information

A voided check or a direct deposit bank letter is attached to provide confirmation of Identification/Account Numbers. The direct deposit bank letter must be dated within 90 days of the application date and preferably notarized. Browse to upload voided check/direct deposit bank letter image in these formats: gif, png, jpg, jpeg, tiff, or pdf. Files must be less than 4MB in size. To submit your request, an image of the voided check or a direct deposit bank letter must be attached.
Date must be within 60 days from the current date. Date must be in MM/DD/YYYY (i.e. '04/30/2018' format).

Fidelis Legal Notice

This FIDELIS CARE system is solely for use by authorized users or customers conducting FIDELIS CARE business. To protect the system from unauthorized use and to ensure that the system is functioning properly, individuals using this computer system are subject to having all of their activities on this system monitored and recorded by FIDELIS CARE system personnel. By using this system you expressly consent to such monitoring.

Moreover, if such monitoring reveals evidence of possible abuse or illegal activity, FIDELIS CARE is authorized to take whatever legal action it deems necessary, including providing the results of such monitoring to appropriate regulatory and law enforcement officials. Your unauthorized use of this system may subject you to civil and potential criminal penalties. Evidence of unauthorized use collected during monitoring may be used as FIDELIS CARE deems necessary.

To submit your request, you must select that you agree to the above.
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