MAYO CLINIC
Mayo Clinic Health Solutions
200 First Street SW · Rochester, MN 55905
Electronic Funds Transfer
Authorization Form
Form EFT-2024 Rev. 03
This form is used to authorize electronic transfer of funds directly to your designated bank account. Please complete all required fields below and return the signed form to your financial institution. Unauthorized access to this document is strictly prohibited.
Payee Information
Transfer Contact Information
Financial Institution Information
Financial Institution Name
Account Type
☐ Checking☐ Savings
Submission Information
By signing below, I authorize the above-named financial institution to initiate electronic fund transfer entries to my account and I agree to abide by the NACHA Operating Rules and Guidelines.
Authorized Signature
Print Name
Title / Position
Date Signed
▶
SIGNATURE REQUIRED — SIGN ABOVE TO AUTHORIZE EFT PAYMENT
Document ID: EFT--XXXX · Protected under NACHA guidelines · Unauthorized duplication prohibited
