CMS-588: Revisions Crosswalk

Revisions Crosswalk – Electronic Funds Transfer (EFT) Authorization Agreement (Form CMS-588)

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reason for the Change
	1	Part I – Reason for Submission	Add checkbox indicating change of ownership	See change in Actions to be Performed column	Added to offer the provider/supplier the chance to report a change of ownership, which is one of the most common reasons for payment delay.
	1	Part 1 – Reason for Submission	Add checkbox indicating change of practice location	See change in Actions to be Performed column	Added to offer the provider/supplier the chance to report a change of practice location, which is one of the most common reasons for payment delay.
	1	Part II – Provider or Supplier Information	Add lines for indicating a change in practice location, if applicable	See change in Actions to be Performed column	Added for the provider/supplier to report a change of practice location, if applicable.
	2	Part IV – Authorization	Add word “designated” between “Services” and “fee” on line 1	See change in Actions to be Performed column	Added “designated” to help clarify which contractor is to be completed for authorization.
	2	Part IV – Authorization	Add “(i.e., the name of the contractor that is processing this enrollment application)” between the word “contractor,” and the blank line	See change in Actions to be Performed column	Added example to help the provider/supplier understand which contractor is to be completed for authorization.
	2	Signature Line	Add half line date field under “Authorized/Delegated Official Signature”	See change in Actions to be Performed column	Added to include date signed.
	2	Signature Line	Add half line telephone number field under “Authorized/Delegated Official Signature”	See change in Actions to be Performed column	Added in order to communicate with Authorized/Delegated Official.
	2	Privacy Act Advisory Statement	Delete the 2nd paragraph	See change in Actions to be Performed column	Deleting reference to update with more current regulation.
	2	Privacy Act Advisory Statement	Add new 2nd paragraph to Privacy Act Advisory Statement	Add, “Per 42 CFR 424.510(e)(1), providers and suppliers must agree to receive electronic funds transfer (EFT) at the time of enrollment, revalidation, change of Medicare contractors where the provider or supplier was already receiving payments via electronic funds transfer or submission of an enrollment change request; and (2) Submit the CMS-588 form to receive Medicare payment via electronic funds transfer.”	Adding paragraph to update and explain current regulation.
	3	Part II – Identification Data	Add instructions for change of practice location, if applicable	Line 8 – If reporting a change of practice location, enter the changed address line 1. Line 9 – If reporting a change of practice location, enter the changed address line 2, if applicable. Line 10 – If reporting a change of practice location, enter the changed address City, State and Zip Code.	Adding instructions to report change of practice location, if applicable.
	3	Part III – Depository Information (Financial Institution)	Renumber lines 8 through 14 to 11 through 17	See change in Actions to be Performed column	Renumbered to account for additional instructions on page 3, part II
	3	Part IV – Authorization	Renumber line 15 to line 18	See change in Actions to be Performed column	Renumbered to account for additional instructions on page 3, part II

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Revisions Crosswalk – CMS588 - 01042010