Bank Account & Payment Setup

Five short steps. Complete them in one sitting — your details are submitted at the end.

Secure form · 256-bit encrypted

Corrections requested — please review and resubmit

Fix the highlighted fields to continue. Nothing has been submitted yet.

Provider Identifiers Step 1 of 5

Provider type *

Individual Provider Individual NPI, SSN or individual TIN Organization Group or Type 2 NPI, EIN

Group NPI (Type 2) *

EIN / Tax Identification Number *

Legal Business Name (LBN) *

Banking Details Step 2 of 5

Routing Transit Number *

Financial Institution Name *

Account Number *

Confirm Account Number *

Account Type *

Checking Savings

Name on Bank Account *

This does not match . The name on the account must precisely match the legal business or provider name, or verification will be declined.

Account Verification Document Step 3 of 5

Upload one of the two documents below. It must show the account name, routing number and account number. PDF, JPG or PNG · max 10 MB.

Voided Check Option A

Official Bank Letter Option B

Payment Notifications Step 4 of 5

Remittance Email *

Additional Email

Copied on every payment notification.

Email an EFT payment notification each time funds are released

I confirm the name on the bank account precisely matches the legal business name or provider name given above, and that the routing and account numbers are correct. * I authorize TPA Exchange to deposit payments to this account and to debit it to reverse any payment made in error. * This submission is logged to the audit trail with your name, IP address and timestamp.

Review & Submit Step 5 of 5

Verification takes 4–5 business days. We send a $0.00 prenote to your bank before the first live payment. Payments stay on your current method until this account is Active.

Submitted — pending verification Reference · submitted Pending

A confirmation and every future payment notification go to .