STATE MEDICAID ELECTRONIC HEALTH RECORD INCENTIVE PROGRAM STAGE 1 AND 2 ATTESTATION REFERENCE GUIDE

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1 STATE MEDICAID ELECTRONIC HEALTH RECORD INCENTIVE PROGRAM STAGE 1 AND 2 ATTESTATION REFERENCE GUIDE ELIGIBLE PROFESSIONALS AHCCCS 801 East Jefferson Street Phoenix, Arizona (602)

2 Table of Contents LOGGING ON... 5 WELCOME TO YOUR EPIP ACCOUNT... 6 MANAGE MY ACCOUNT... 7 MY ACCOUNT DETAILS... 8 ATTEST... 9 ATTESTATION PROGRESS PATIENT VOLUME CRITERIA REPORT PATIENT VOLUMES REPORT HOSPITAL-BASED ENCOUNTERS PROVIDER ELIGIBILITY RESULTS ATTESTATION PROGRESS PATIENT VOLUME REPORT UPLOAD DOCUMENT PATIENT VOLUME REPORT ATTESTATION PROGRESS HOSPITAL MEDICAID BASE REPORT UPLOAD DOCUMENT HOSPITAL-BASED REPORT ATTESTATION PROGRESS ATTESTATION INFORMATION ATTESTATION INFORMATION ATTESTATION PROGRESS MEANINGFUL USE CORE MEASURES MEANINGFUL USE CORE MEASURES CORE MEASURE SUMMARY MU ATTESTATION PROGRESS MEANINGFUL USE MENU MEASURES MENU MEASURE SUMMARY ATTESTATION PROGRESS MEANINGFUL USE CLINICAL QUALITY MEASURES SUMMARY OF CLINICAL QUALITY MEASURES ATTESTATION PROGRESS MEANINGFUL USE EHR REPORT UPLOAD DOCUMENT MU REPORT ATTESTATION PROGRESS COMPLETE SUBMISSION PROCESS: ATTESTATION STATEMENTS PAYMENT ASSIGNMENT AGREEMENT ATTESTATION DISCLAIMER SUBMISSION RECEIPT SUMMARY OF MEASURES APPENDICES APPENDIX A PATIENT VOLUME REPORT FIELDS Page 2 of 48

3 APPENDIX B - DEFINITIONS APPENDIX C FREQUENTLY ASKED QUESTIONS APPENDIX D ELECTRONIC FUNDS TRANSFER Page 3 of 48

4 Disclaimer The Arizona Health Care Cost Containment System Administration (AHCCCS) is providing this material as an informational reference for physician, non-physician practitioner and providers. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of posting, the Medicare and Medicaid program is constantly changing, and it is the responsibility of each physician, nonphysician practitioner; supplier or provider to remain abreast of the Medicare and Medicaid program requirements. Medicare and Medicaid regulations can be found on the CMS Web site at Important Notice Third Party Attestation The Arizona Medicaid Program does not allow third party attestation for Eligible Providers in the Electronic Provider Incentive Payment System (epip). Eligible Providers should actively participate in the attestation process in epip. Eligible providers are responsible for the completeness and accuracy of the information provided in their attestation in epip. Page 4 of 48

5 Logging On Insert your user ID (your Medicaid Provider Number) Insert your password. A minimum of six characters is required. Click Log On Your User ID is the same as your Medicaid Provider Number. If you have forgotten your password, click on the link to have it reset. Page 5 of 48

6 Welcome To Your epip Account From this page you will be able to navigate to everywhere you need to go to attest for Meaningful Use. You will be able to verify or change your account information. You will be able to upload documents that you need for attestation. You will be able to submit your attestation. If a word is bold blue and underlined, you can click on it to go to another page. Take a minute and familiarize yourself with the links to different options. To return to a previous screen, click on the directional arrow in upper left hand corner of your screen. Page 6 of 48

7 Manage My Account We recommend that you look at your personal account information and make certain that everything is current and accurate. There are directions and links below each section on how to make changes if the information is not correct. Page 7 of 48

8 My Account Details Some fields will be auto populated based on your registration with CMS. Review all fields in all sections to make sure that the information is current and accurate. If you need to make changes in the CMS Information section click on the link. Remember to update your submission in CMS and allow 48 hours for changes to automatically be reflected in epip from your CMS registration. Note that it is on the bottom of this page, you also have the option of changing your password. Page 8 of 48

9 Attest The upper portion lists your attestation history. Your actual CMS Certification ID for your EHR System will be listed here. If your EHR software has changed or been upgraded since your last attestation, you will need to upgrade this field at the CMS website: cms.gov It may be necessary for you to verify your CMS EHR Certification Number with your EHR vendor. Click Begin to start your Attestation. If you do not see Begin/Edit/Resubmit Contact the EHR Team at or Instead of Begin you may be given the options of Edit or Resubmit if you have already started your attestation. Read further down on the page for details. Page 9 of 48

10 Attestation Progress Click on Modify on the Contact Information line and complete the required fields. Note that and phone contact detail under Manage My Account may often be generic to a group. The required phone and fields in the Contact Information link on this screen ask for attestation specific information. This protects the provider in the event of a relocation or change of practice. Failure to respond to AHCCCS may delay incentive payments to EPs. Next, click on Begin on the Patient Volume option and enter the required data. You will not have visibility to subsequent sections Contact Information is completed. Note that the ability to begin completion of the fields in any section on this page is sequential. You must complete the sections in sequence (top down) to access subsequent sections. Page 10 of 48

11 Patient Volume Criteria Select which mix of patient volume type and methodology you wish: Medicaid patient volume and individual patient volume counts. Medicaid patient volume and group aggregate patient volume counts. Needy individual patient volumes and individual patient volume counts. Needy individual patient volumes and group aggregate patient volume counts. Note There are several possible combinations of Patient Volume and Patient Volume Methodology for the Eligible Professional to select (see the right column). Not all of the screens are displayed in this guide. Note that, in some cases, a provider may already be associated with an aggregate patient volume submission and this page will not be accessible for completion. An Eligibility Worksheet for determining Patient Volume, Aggregate Patient Volume Needy Individual Patient Volume is found on the AHCCCS website at the following link: Select Provider Toolkit on the left. Select Eligible Professional and click on the Establish Practice request Form link in the center of the page. Page 11 of 48

12 Report Patient Volumes Enter the dates from the prior calendar year (90 days) that you wish to use to establish the Medicaid patient volumes. For example: If you are attesting to your Meaningful Use in Program Year 2014, you would want to select a 90 day period sometime between January 1, 2013 and December 31, 2013 that demonstrated that 30% of your patient volumes were Medicaid (20% for Pediatricians). Enter the total patient encounters. Enter the Medicaid patient encounters. Submission of Medicaid patient data from bordering states is optional. EPs must attest in the state where services were provided. Note that submission of border state Medicaid patient volumes is optional and only recommended if you are having trouble meeting the threshold for eligibility. Border state patient volumes have to be verified with the state(s) involved and will slow down incentive payment approval. Page 12 of 48

13 Report Hospital-Based Encounters Enter the 12 month period of the prior calendar year from the Program Year in which you are attesting. Enter the total number of Medicaid patient encounters. Enter the number of Medicaid inpatient encounters. Enter the number of Emergency Department Medicaid patient encounters. If the volume is zero (0) you must enter a zero (0). Example: For those eligible professionals gathering core and menu Meaningful Use data in 2014 for attestation, their submission of hospital based data would be for the period beginning 1/1/13 and ending 12/31/13. Again, the data required for reviewing your hospital based Medicaid patient encounters (Inpatient and Emergency Department) must be for the full prior calendar year prior to the year in which you are attesting. Page 13 of 48

14 Provider Eligibility Results After reviewing your Eligibility results, click Save and Continue. If a mistake has been made with data entry and the Patient Volume or Hospital Based Percentages indicate ineligibility, click on the Previous button. If you are not certain you have entered all applicable data, Contact the EHR Team at or Patient volume eligibility criteria for Eligible Professionals (EPs) are 30% (20% for Pediatricians). If the hospital based percentage is 90% or more, the EP is not eligible for the EHR incentive payment from Medicaid. Page 14 of 48

15 Attestation Progress Patient Volume Report Return to the Attestation Progress Screen and select Begin on the Patient Volume Report line. Note that if you are using Aggregate Patient Volume: from your group practice, epip may recognize your association with that group and autopopulate this field. To navigate to the Attestation Progress screen, click on Attest on the left and select Edit on your current attestation line. Page 15 of 48

16 Upload Document Patient Volume Report Upload the file from your computer that establishes Medicaid Patient Volumes. If aggregate data has previously been submitted, EPs need to submit a simple Word document stating that aggregate data was submitted prior to attestation. See Appendix A for an example of the patient volume data that should be submitted. Do not this data to AHCCCS. Use the Upload Document tool in epip. Contact the EHR Team at or Once you have uploaded this data, you can verify the upload by scrolling through the document list to verify the most recent uploads or using the Manage Documents tab on the left of the screen. Do not this data. That places you at risk for a significant security breach and HIPAA violation. Use the Upload Document tool in epip. Page 16 of 48

17 Attestation Progress Hospital Medicaid Base Report Return to the Attestation Progress screen and click on Begin on the Hospital Base Report line. To navigate to the Attestation Progress screen, click on Attest on the left and select Edit on your current attestation line. Page 17 of 48

18 Upload Document Hospital-Based Report Upload the file from your computer that establishes Medicaid Hospital Based Patient Volumes. If your Hospital Based Patient Volume is zero (0), please upload a document stating such and that you are not hospital based. This does not have to be on practice letterhead. You can verify the upload on the Manage Documents Tab on the left. Page 18 of 48

19 Attestation Progress Attestation Information Return to the Attestation Progress screen and click on Begin on the Attestation Information line. To navigate to the Attestation Progress screen, click on Attest on the left and select Edit on your current attestation line. Page 19 of 48

20 Attestation Information All fields on this page are required for completion. When done, click Next. To return to Attestation Progress to verify how you answered these questions previously, click on Return to Attestation Progress. CEHRT stands for Certified Electronic Health Records Technology. It is the unique certification number for the EHR software that was in use during your reporting period. If you are uncertain, contact your EHR software vendor. Page 20 of 48

21 Attestation Information Continued Review the detail that is presented on this page. If there is an error, Click on Previous and make corrections. If everything is accurate, click Save and Continue The fields on this page will be populated with your specific answers from the previous screen. Review for accuracy before proceeding. Page 21 of 48

22 Attestation Progress Meaningful Use Core Measures Click Begin on the Attestation Progress screen on the Meaningful Use Core Measures line. To navigate to the Attestation Progress screen, click on Attest on the left and select Edit on your current attestation line. Page 22 of 48

23 Meaningful Use Core Measures Determine if you can take an exclusion on this measure and click the appropriate button. Click to select the source of patient records. If all records are contained within the EP s EHR choose the second option. Enter the numerator and the denominator. Important The process for completing the remaining pages on Core Measures is repetitive. We have not provided screen shots on each measure. Click Save and Continue. The next page will take you to the Core Measure Summary where you have a chance to review and edit your responses to all of the Core Measures. Unless you use data from a source external to your certified electronic health record technology (CEHRT) the data for the numerator and denominator will come from your CEHRT report. Page 23 of 48

24 Core Measure Summary MU Your answers to the core measure questions will be summarized in the Entered column. Click on Edit to change the answers if there are errors. Note due to the size, the entire page is not displayed here. When have checked your answers, click Continue. We have provided just a sample of the first and last page of the Core Measure Summary. The actual summary will be longer in epip. Page 24 of 48

25 Attestation Progress Meaningful Use Menu Measures Click Begin on the Attestation Progress screen on the Meaningful Use Menu Measures line. To navigate to the Attestation Progress screen, click on Attest on the left and select Edit on your current attestation line. Page 25 of 48

26 Meaningful Use Menu Measures EPs attesting to Stage 1must choose five (5) Menu measures. EPs attesting to Stage 2 must choose three (3) Menu measures. When you are ready to attest to the Menu Measures that you have selected, click Start Choose five Menu measures if you are attesting to Stage 1. Choose three Menu measures for Stage 2. EPIP will not accept an exclusion as a Menu measure. EPIP will have you select another menu measure to meet the required measures or claim an exclusion on all menu measure options. Page 26 of 48

27 Meaningful Use Menu Measures This is a sample page of one of the menu items that can be selected. Important The process for completing the remaining pages on Menu Measures is repetitive. We have not provided screen shots on each measure. When you have completed each Menu Measure that you have selected, click Save and Continue. The next page will take you to the Menu Measure Summary where you have a chance to review and edit your responses to all of the Menu Measures. When working with an external organization (Public Health) for Menu Measures, make sure that you obtain documentation from them that is date/time stamped stating that you have complied with program requirements. Contact ADHS at: Page 27 of 48

28 Menu Measure Summary This is a sample of the summary page for three Menu Measures selected. Yours may vary. View your responses in the Entered column. Edit any of your responses that you wish to change. Click Continue when you are ready to proceed. Remember that you cannot take an exclusion if there is another Menu Measure to which you can attest. Page 28 of 48

29 Attestation Progress Meaningful Use Clinical Quality Measures Return to the Attestation Progress page and click Begin on the Meaningful Use Clinical Quality Measures line. There are no right or wrong Clinical Quality Measures numbers, however; they must be generated by your Certified Electronic Health Record Technology (CEHRT). Page 29 of 48

30 Meaningful Use Clinical Quality Measures Carefully read the instructions for this section. Consider selecting the Recommended CQMs if they fit your practice. Note: The full page is too large for display. Once you have selected your nine (9) CQM s, click Start. For assistance with CQM reporting, view the 2014 Clinical Quality Measure (CQM) Electronic Reporting Guide. Guidance/Legislation/EHRIncentivePrograms/Downloads/CQM2014_GuideE P.pdf Page 30 of 48

31 Summary of Clinical Quality Measures Review your CQM attestation answers in the Entered column. Click Edit to change your response if needed. Note: The full page is too large for display. Click Return to Attestation Progress when you have completed your CQM review and edits. To navigate to the Attestation Progress screen, click on Attest on the left and select Edit on your current attestation line. Page 31 of 48

32 Attestation Progress Meaningful Use EHR Report On the Attestation Progress screen, click Begin when you are ready to upload your Meaningful Use EHR Report This will take you to the screen for uploading supporting data. Page 32 of 48

33 Upload Document MU Report Select the MU report data saved to file from your Certified Electronic Health Record software and click on Upload Document. If your EHR software supports EXCEL, please submit this report in EXCEL. In your certified EHR software, there will be a report suite that allows you to print the results (numerators/denominators or Yes/No) of your core, menu and clinical quality measure compliance. If you select PDF instead of a printer, this will give you an electronic copy for uploading to epip without having to scan the document for uploading. Page 33 of 48

34 Attestation Progress Complete All Attestation Progress fields should now show Completed Click Continue Attestation. If you are uncertain of compliance in any area, click on the Modify field to review your responses. Page 34 of 48

35 Submission Process: Attestation Statements Your EHR software certification number will automatically be placed here. To attest, you must check each of the boxes and the click on Agree. Agree will only become an active button once you have checked all of the boxes. Page 35 of 48

36 Payment Assignment Agreement The top five fields on this page will be auto populated by epip. The Employer field is a required field to proceed. Check this box to activate the Submit Attestation button. Clicking on this link will give you access to IRS form Click on this button to submit your attestation. If epip recognized the submission of your attestation, you should next see an Attestation Disclaimer page. If you do not, make sure that all required fields on this page are complete and click Submit Attestation again. Page 36 of 48

37 Attestation Disclaimer Carefully read the attestation Notification and Disclaimer. Check this box if you agree to the disclaimer. Click here to submit your application. If epip received your attestation submission, your next screen should be a Submission Receipt. Page 37 of 48

38 Submission Receipt This is your Submission Receipt designating acceptance or rejection. These four fields will be auto populated by epip. Note that it contains your Attestation Confirmation Number We suggest that you print a copy of this page. (If you receive a rejection, click Summary of Measures to identify which measure(s) caused the rejection. the EHR Incentive Program at when you are ready to resubmit. Congratulations. Page 38 of 48

39 Summary of Measures This page will be auto populated with your specific detail. You may review the details of your attestation responses and data submissions and make any necessary corrections. As noted previously, if you receive a rejection, the EHR Incentive Program at when you are ready to resubmit. Page 39 of 48

40 Appendices Appendix A Patient Volume Report Fields Report Fields Page 40 of 48

41 Appendix B Definitions Electronic Heath Record (EHR) a digital documentation of a member s medical history that is portable and sharable across systems of care Eligible Hospital (EH) a hospital with a patient population that is at least 10% Medicaid and meets the requirements laid out in the Final Rule Eligible Professional (EP) a physician, nurse practitioner, certified nurse-midwife, dentist or physician assistant that leads an FQHC or RHC and has a patient panel that is at least 30% Medicaid members (pediatricians can qualify with a 20% Medicaid patient panel) Exclusion a reason or reasons associated with a Meaningful Use objective that can be selected, if applicable, to exempt a provider from having to meet the measure Exemption found mainly in the Clinical Quality Measures, this counts the number of members that were seen by a provider during the Meaningful Use Reporting Period, but were not eligible to be included in the measure being reported on Hospital Base (HB) the count and percentage of Medicaid patients that are seen in an Emergency Department or Inpatient setting versus the total number of Medicaid members seen in a given year Meaningful Use (MU) Using certified electronic health record technology to improve quality, safety, efficiency, and reduce health disparities; engage patients and families; improve care coordination and population/public health, and maintain privacy and security of patient health information. Meaningful Use Reporting Period a 90-or 365-day period from the Program Year in which a provider is attesting (i.e. for Program Year 2014 attestations, the Meaningful Use Reporting Period would be a 90-day period between January 1, 2014 and December 31, 2014). Participation Year the number of years that a provider has received an incentive payment; EPs are eligible for up to six participation years while EHs can participate for four years Patient Volume (PV) the percentage of Medicaid encounters (unique visits) vs. the total number of encounters (all patients) during the reporting period Patient Volume Reporting Period a 90-day period from the prior calendar year of the Program Year for which a provider is attesting (i.e. for Program Year 2014 attestations, the Patient Volume Reporting Period must be a 90-day period between January 1, 2013 and December 31, 2013). Program Year The year in which a provider is attesting; for EPs, the Program Year is based on a January-December calendar year, for EHs the Program Year is an October- September Federal Fiscal Year Reporting Period a length of time that is analyzed for purposes of demonstrating either patient volume or meaningful use Stage 1, Phase 1 the Meaningful Use requirements for Program Year 2012 Stage 1, Phase 2 the Meaningful Use requirements for Program Year 2013 Stage 1, Phase 3 the Meaningful Use requirements for Program Year 2014 and beyond (prior to introduction of the Flexibility Rule) Tail Period the length of time following the end of a Program Year in which providers can submit an attestation for the recently ended Program Year (e.g. the tail period for Program Year 2013 was January 1, 2014 through April 30, 2014). Page 41 of 48

42 Appendix C Frequently Asked Questions Q What is the difference between the Medicare and the Medicaid EHR Incentive A Program? With Medicare, there is no minimum threshold of Medicare patients that must be seen by an Eligible Professional (EP) to qualify for incentives. Incentives for those EPs attesting for the first time in 2014 total $23,520 over 3 years with the first attestation being for 90 continuous days in a calendar year. With Medicaid, Eligible Professionals must have 30% of their patient population be Medicaid members (20% for Pediatricians). For EPs attesting for the first time in 2011 through 2016, incentives total $63,750 over 6 years. Q A Can I switch between Medicare and Medicaid programs? Providers can switch between the Medicare and Medicaid programs any time before they receive their first incentive payment. Eligible Professionals can switch one time (before 2015) between the Medicare and Medicaid Incentive Programs if they have received one incentive payment. Q Can I skip a year after I have started the EHR incentive program? A Those EPs in the Medicare EHR incentive program must attest in consecutive years. Those EPs in the Medicaid EHR incentive program can skip a year without penalty. It is not necessary to notify Medicaid that you are skipping a year. When you continue, you continue in the program year that you would have started in if you had not skipped a year. Page 42 of 48

43 Appendix C Frequently Asked Questions cont d. Q A After Registration, what supporting documentation do I need to complete my attestation for Stage 2 of the EHR Incentive Program? To attest to Stage 2, you will need to document the following information: The Patient Volume Reporting Period (90 Days) data from the prior calendar year that precedes your program year. This establishes your Medicaid and total patient volumes. The Hospital Based Reporting Period (12 Months) from the entire prior calendar year that precedes your payment year that establishes your Medicaid and total patient volumes. The Patent Volume Methodology that you choose: o For Individual Patient Volume Methodology: Patient Volume criteria is based on Provider s data Hospital-Based criteria is based on Provider s data o For Aggregate Patient Volume Methodology: Patient Volume criteria is based on Practice s data Hospital-Based criteria is based on Provider s data The Total Patient Encounters (Individual or Practice Aggregate) The Medicaid Patient Encounters (Individual or Practice Aggregate) The Hospital-Based Patient Encounters (Medicaid Title XIX Inpatient Hospital & Emergency Department) Note: Non-Hospital-Based Criteria EPs selecting Medicaid Patient Volume Type cannot be hospital-based. Hospital-Based Patient Encounters are encounters received at an inpatient hospital or an emergency department place of service. Hospital-Based EPs have 90 percent or more of their covered professional services in a hospital setting during the 12-month reporting period. Page 43 of 48

44 Appendix C Frequently Asked Questions cont d. Q Can a provider attest multiple times in a calendar year? A It is possible for a provider to attest multiple times in a calendar year as long as the attestations are for separate Program Years. For instance, a 2014 attestation could be completed during the Program Year 2014 tail period in 2015 and a Program Year 2015 attestation could be completed later in 2015, assuming that a payment decision has been issued for the Program Year 2014 attestation. Q Can a provider receive multiple attestation payments in a calendar year? A It is possible for a provider to receive multiple attestation payments in a calendar year as long as the payments are for separate Program Years. Q I am ready to start a new attestation but I do not see that option when I log in to epip. What are the possible reasons for such? A If a payment decision has not been issued for the prior Program Year in which you attested, you cannot begin a new Program Year attestation. If your previous attestation was denied or rejected, you may need to have your attestation capabilities unlocked. In any instance where you cannot start a new Program Year and you believe you should be able to, please contact the EHR Incentive Program team at or Page 44 of 48

45 Appendix C Frequently Asked Questions cont d. Q I have successfully submitted my attestation; how long will it take to receive a payment? A Once an attestation has been successfully submitted, it must go through the prepayment audit process. The EHR Incentive Team strives to complete the process within eight (8) weeks of attestation; however, if there are questions about the data submitted or missing information, it can take longer to issue a decision and release a payment (if the attestation is approved). If you have payment inquiries, please contact the EHR Incentive Program team at or Q I am choosing to reassign my attestation payment to my practice. Will I have any financial liability if I do so? A At this time, AHCCCS only issues 1099s to actual recipient (payee) of the attestation funds. If you have reassigned your payment to your practice, you will not personally receive a 1099 for those monies. For more information on 1099s, visit the AHCCCS website at and look for the IMPORTANT ATTESTATION PAYMENT INFORMATION about half way down the page. Page 45 of 48

46 Appendix D Electronic Funds Transfer Completing the ACH Vendor Authorization Form This page provides step by step instructions for completion of the automated clearing house (ACH) Vendor Authorization Form for electronic funds transfer. Section 1 The Arizona Health Care Cost Containment System (AHCCCS) will only transfer funds for the Electronic Health Records Incentive Program electronically. The ACH form (sample provided after these instructions) can be used for any of the following: New ACH set-up Changing the Account Type Changing the Account Number Changing the Financial Institution Cancelation of the ACH Request Note that with cancelation, Sections 2, 3 and 5 must still be completed. Section 2 Line 1 If assigning your EHR incentive payment to a group practice or other entity, enter the Federal Employer s Identification Number (EIN) on line 1. If you are receiving the EHR incentive payment individually, enter your social security number (second option line 1). Always complete the AHCCCS provider Number and Locator Code. Failure to enter the Locator Code may result in slowing down your payment. If you do not know your Locator Code, call or or and request your Locator Code. Line 2 If you have selected the EIN assignment option, place the name of the group or entity to which the payment will be sent on the Payee s Name line and complete the Provider s Name line. If you selected the SSN payment option, just complete the Provider s Name line. Line 3 Always provide the business telephone number of the option selected (group/entity or provider). Line 4 If you have entered the Employer Identification Number (EIN), enter the group or entities address. If you entered the social security number (SSN) enter the provider s address. Page 46 of 48

47 Appendix D Electronic Funds Transfer cont d. Section 3 Line 6 Select Yes if you approve your financial institution to process your corporate trade exchange (CTX) payment/transactions along with addendum information. Line 7 If you entered an EIN in Section 2, place the group or entities payee name on this line. If you entered a SSN, place the name of the provider on this line. Lines 8 and 9 If you entered an EIN in Section 2, place (respectively) the title and signature of the group or entities authorized representative on these lines. If you entered SSN in Section 2, place the provider s title and signature (respectively) on these lines. Section 4 This section must be completed and signed by a representative of the financial institution that will be processing the electronic payment. Section 5 Lines 21 and 22 Complete, along with Sections 2 and 3, if this form is being used for cancellation of a previous form submission. Section 6 Section 6 is for AHCCCS use only. Page 47 of 48

48 Appendix D Electronic Funds Transfer cont d. Page 48 of 48

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