Tips for Completing the Electronic Funds Transfer (EFT) Form

Completing the EFT form
Documents not returned within the 14-day enrollment period will be denied.

The Details

What you need

Electronic Funds Transfer FormProviders must complete the authorized-signature (and date) field on the EFT form. An original signature of the individual provider or authorized signature of the business is required. Note: The Commonwealth requires town treasurers to sign EFT requests for the town’s EFT forms.

Include the following documentation:

Voided check. The voided check must include a preprinted provider name and address. This area cannot be blank, handwritten, or stamped. A bank deposit form is not acceptable in lieu of a voided check; or

Bank letter that includes the bank name, provider name, bank account number, and routing number. If the Tax ID is detailed on the bank letter, it must match the Tax ID on the EFT form and MassHealth provider file or enrollment documentation. Note: The bank transit routing number (ACH ABA number) is generally not included on the bank statement. Note: The wire transfer number is not needed. These numbers must match the information provided on the check or bank attachment(s); or

Bank statement from the designated account. Note: A bank statement details the bank name, provider name, and bank account number only. A bank deposit form is not acceptable in lieu of a bank statement.

How to submit

Complete the EFT form--you can download it below. This is the only acceptable form for a MassHealth provider application for electronic payment.

Mail the hard copy of the completed EFT form to MassHealth with your original signature. Copies and faxes are not acceptable.

Mail your signed completed form to the following address.

MassHealth Customer Service
Attn: Provider Enrollment and Credentialing
P.O. Box 9162
Canton, MA 02021

Dental providers should mail their signed, completed form and required documentation to DentaQuest at the following address.

MassHealth Dental Program
Attn: Provider Enrollment and Credentialing
12121 N. Corporate Parkway
Mequon, WI 53092

More info

The Office of the Comptroller and the Office of the State Treasurer have mandated that all providers enrolled in MassHealth, including individual practitioners who will receive payments directly, participate in EFT. EFT payments are automatically deposited into a designated bank account. They are less expensive to process, highly dependable in getting deposited into a provider’s account, and processed in a secure manner. EFT is helpful in streamlining operations by reducing paperwork, and it functions as a convenient and effective electronic method of reimbursement.

MassHealth is committed to having 100% compliance to EFT. All providers are expected to be paid via electronic direct deposit. In addition, EFT participation is now required when a provider submits a new enrollment application to MassHealth. The EFT Form will be processed upon enrollment.

Individual practitioners who are enrolled/enrolling as part of a group practice and will not submit claims for payment under their individual national provider identifier (NPI) must enroll with MassHealth as a “no pay” provider. EFT is not required. Enrolling as a “no pay” provider also eliminates the requirement of submitting the Massachusetts Substitute W-9, Data Collection Form (DCF), and Trading Partner Agreement. Applicants submitting paper applications should write “no pay” in Section I of the application, to the right of Field 11. Those submitting applications via the Provider Online Service Center (POSC) must include a “no pay” statement when they submit the Provider Agreement.

Applications received without an EFT form or “no pay” designation will be returned to the provider for completion. Documents not returned within the 14-day enrollment period will be denied. Exceptions to this mandate are not expected.



P.O. Box 121205, Boston, MA 02112-1205


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