Electronic Payment & Remittance

Thank you for your interest in signing up for electronic payments and remittances!

Please be sure to complete the forms entirely. Move your pointer over the question mark [?] for an explanation of what information is being requested.

If you have any questions about these instructions or are unsure of how to complete these authorizations you may email your questions to PharmacyAccountingIssues@EnvisionRx.com or call us toll free at 1-800-361-4542 and ask for pharmacy payables.

Once you have submitted these forms on line be sure to send us a copy of a voided check or a letter on bank letterhead so we can confirm your routing/account numbers. Be sure to include your NCPDP number so we can match this with your authorization. This information can be emailed to PharmacyAccountingIssues@EnvisionRx.com, faxed to 330-486-4801 (Attn: Pharmacy Payables), or mailed to EnvisionRx (Attn: Pharmacy Payables), 8957 Canyon Falls Blvd, Twinsburg, OH 44087.

Electronic Funds Transfer Authorization Form
Provider Information
This is the complete legal name of your institution or corporate entity.
The complete street address where this institution or corporate entity is located.
The city where this institution or corporate entity is located.
The state/province where this institution or corporate entity is located.
The zip code/postal code where this institution or corporate entity is located.
Provider Identifiers
Please enter your full 9 digit Federal Tax ID number
Please enter your full 10 digit NPI. If you do not have an NPI enter n/a.
Provider detailed information
Enter the first name of your contact person who handles EFT issues.
Enter the last name of your contact person who handles EFT issues.
Enter the telephone number of the contact person who handles EFT issues.
Enter the email address of the contact person who handles EFT issues.
Provider Pharmacy information
This is the complete name by which your pharmacy is known.
Enter the assigned payment center identifier associated with your institution or corporate entity. Enter N/A if this does not apply.
Enter your NCPDP number.
This is the official name of the financial institution where your deposit account is held.
The complete street address of the financial institution where your deposit account is held.
The city of the financial institution where your deposit account is held
The state/province of the financial institution where your deposit account is held.
The zip code/postal code of the financial institution where your deposit account is held.
"Enter the telephone number for a contact person at the financial institution where your deposit account is held.
Type of Account at Financial Institution: Checking
This is the 9 digit identifier of the financial institution where your deposit account is held. It can be found at the bottom of your check between the colons (see example). example
This is the checking account number to which EFT payments are to be deposited (see example). example
Account Number Linkage to Provider Identifier Choose one:
Enter your TIN. If you receive an Electronic Remittance Advice this must match your preference for aggregating the remittance data.
Enter your NPI. If you receive an Electronic Remittance Advice this must match your preference for aggregating the remittance data.
Select the reason you are submitting this form by checking the corresponding box.
Select the documentation you will supply. Please submit your choice by Fax to 330-486-4801 or by e-mail to pharmacyaccountingissues@envisionrx.com. Be sure to include your NCPDP or NPI so we can link back to your authorization form.
Electronic Remittance Advice Authorization Form
Provider Information
This is the complete legal name of your institution or corporate entity.
The complete street address where this institution or corporate entity is located.
The city where this institution or corporate entity is located.
The state/province where this institution or corporate entity is located.
The zip code/postal code where this institution or corporate entity is located.
Provider Identifiers
Please enter your full 9 digit Federal Tax ID number
Please enter your full 10 digit NPI. If you do not have an NPI enter n/a.
Provider detailed information
Enter the first name of your contact person who handles ERA issues.
Enter the last name of your contact person who handles ERA issues.
Enter the telephone number of the contact person who handles ERA issues.
Enter the email address of the contact person who handles ERA issues.
Provider Pharmacy information
This is the complete name by which your pharmacy is known.
Enter the assigned payment center identifier associated with your institution or corporate entity. Enter N/A if this does not apply.
Enter your NCPDP number.
Preference for Aggregation of Remittance
Data (e.g., Account Number Linkage to Provider Identifier)
Enter your TIN. If you receive an Electronic Remittance Advice this must match your preference for aggregating the remittance data.
Enter your NPI. If you receive an Electronic Remittance Advice this must match your preference for aggregating the remittance data.
Method of Retrieval: The provider will be given access to an assigned folder on our secure ftp website.
If you use a third party vendor to receive and reconcile your ERA enter their name here. Otherwise enter “n/a.”
Enter the first name of a contact person in the vendor office who handles ERA.
Enter the last name of a contact person in the vendor office who handles ERA.
Enter the telephone number of the vendor contact person who handles ERA issues. If you do not use a third party vendor enter “n/a”.
Enter the email address of the vendor contact person who handles ERA issues. If you do not use a third party vendor enter “n/a”.
Select the reason you are submitting this form by checking the corresponding box.
Account Authorization
The printed first name of person submitting enrollment.
The printed last name of person submitting enrollment.

*Required.