Jump to content

  • Employers
  • Producers
  • Providers
  • Forms
  • COVID-19 FAQs

Search form

Home
  • Individual Dental Plans
    • Dental & Vision
  • Explore Group Plans
    • Life and AD&D
    • Small Groups (2-25 employees)
    • Short Term Disability
    • Long Term Disability
    • Dental
    • Vision
    • Accident
    • Critical Illness
    • Employee Assistance Program
    • Employer Admin Center
  • Members
    • All Members
      • Find a Provider
      • Submit a Claim
      • Find a Form
      • Get Member Advantages
    • Individual Plan Members
      • Address Change
      • Payment & Billing
      • Login to My Account
      • Ask a Question
    • Group Plan Members
      • Go to Dental Center
      • Employee Assistance Program
      • Global Travel Assistance Program
      • Moving Off an Employer's Plan
      • Benefits Calculators
      • Group Dental ID Card Replacement
  • Employers
  • Producers
  • Providers
  • Forms
  • COVID-19 FAQs

Search form

You are here
  1. Home /
  2. Providers /
  3. Quick Links /
  4. Provider EFT Enrollment Form

Provider EFT Enrollment Form

File: 
PDF icon lifemap_provider_eft_enrollment_form.pdf
State: 
Alaska
California
Idaho
Montana
Oregon
Utah
Washington
Wyoming
Language: 
English
  • Provider Admin
    • Submit a Claim
    • Verify Eligibility
    • Disputes
  • Quick Links
    • Login to Availity Portal
    • Go to Dental Center
    • Enroll in Electronic Funds Transfer (EFT)

Member Dashboard

  • Find a Provider
  • Submit a Claim
  • Make a Payment
  • Get Member Advantages

Employer Dashboard

  • Make a Payment
  • Submit a Claim
  • Find a Form
  • Login to Accounts
  • Request Enrollment Change

Producer Dashboard

  • Individual Business
  • Small Group Business
  • Large Group Business (26+ Employees)

 

For Individual Policies: 1(800) 756-4105

For Group Policies: 1(800) 794-5390

For Claims: 1(800) 286-1129

  • About LifeMap
  • News
  • Careers
  • Contact Us

© 2022 LifeMap Assurance Company® All Rights Reserved

  • Terms of Use
  • Privacy Policy
  • California Consumer Privacy Act
  • Disclosures
  • Non-discrimination
  • Español