Direct Deposit form - Puerto Rico State Level Registry (SLR)

PR Health Insurance Administration
PO Box 195661
San Juan, PR 00919-5661
Authorization for Electronic Funds Transfer (EFT)
Puerto Rico EHR Incentive Payments
Initial Application
Hospital
Group Member
Modification to Initial Application
Individual Professional
Provider Name (Last Name, Second Last Name, Name, Initial)
Provider e-mail Address:
Provider NPI Number:
Provider Tax ID Number:
Provider Mailing Address:
City
Zip Code
Payee Name (Complete this section ONLY if the Payee is other than the Provider):
Payee NPI Number:
Payee Tax ID Number:
Payee Mailing Address:
City
Zip Code
Financial Institution Information
Nine-Digit Routing Number:
Bank Account Number:
Account Holder Name:
Type of Account :
Checking
Financial Institution Name
Savings
Branch:
I authorize ASES to make an electronic payment to the account in the above specified financial institution. This
authorization will remain in effect until cancelled or amended in a written notification. ASES, as administrator of the
incentive payments, has the right to adjust future payments to the provider’s account if payments previously made
are found to be duplicated, in excess of requirements, fraudulent or in error.
Sign and upload this completed form to receive your payments electronically. If no form is received a check will be
issued for the payment.
I hereby certify that the information above is true and correct.
Date:
(month/day/year)
Provider Signature:
Applications for hospitals must be signed by an officer or authorized representative of the entity.
For more information visit the Puerto Rico State Level Registry (SLR) webpage at http://pr.arraincentive.com or
send your inquiries to SLRHelpdesk@xerox.com.