Form CMS-588 EFT_Authorization_Agreement

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved

OMB No. 0938-0626

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT

PART I: REASON FOR SUBMISSION

Reason for Submission:
Check here if EFT payment is being made to
the Home Office of Chain

New EFT Authorization
Revision to Current Authorization

(Attach letter Authorizing EFT payment to
Chain Home Office)

(e.g. account or bank changes)

Since your last EFT authorization agreement submission, have you had a:
Change of Ownership, and/or
Change of Practice Location?
If you checked either a change of ownership or change of practice location above, you must submit a change of
information (using the Medicare enrollment application) to the Medicare contractor that services your geographical
area(s) prior to or accompanying this EFT authorization agreement submission.

PART II: PROVIDER OR SUPPLIER INFORMATION

Provider/Supplier Legal Business Name
Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name)
Account Holder’s Practice Location Street Address
Account Holder’s Practice Location City
Tax Identification Number (designate

Account Holder’s Practice Location State
SSN or

Account Holder’s Practice Location Zip Code

EIN)

Medicare Identification Number (if issued)

National Provider Identifier (NPI)

National Provider Identifier (NPI)

National Provider Identifier (NPI)

PART III: FINANCIAL INSTITUTION INFORMATION

Financial Institution’s Name
Financial Institution’s Street Address
Financial Institution’s City/Town

Financial Institution’s State

Financial Institution’s Zip Code

Financial Institution’s Telephone Number

Financial Institution’s Contact Person

Financial Institution Routing Transit Number (nine digit)

Depositor Account Number

Type of Account (check one)
Checking Account

Savings Account

Please include a confirmation of account information on bank letterhead or a voided check. When submitting
the documentation, it should contain the name on the account, electronic routing transit number, account
number and type. If submitting bank letterhead, the bank officer’s name and signature is also required. This
information will be used to verify your account number.

FORM CMS-588 (XX/13)

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PART IV: CONTACT PERSON

Contact Person’s Name

Contact Person’s Title

Contact Person’s Telephone Number

Contact Person’s E-mail Address

PART V: AUTHORIZATION
I hereby authorize the Centers for Medicare & Medicaid Services (CMS) to initiate credit entries, and in accordance
with 31 CFR part 210.6(f) initiate adjustments for any duplicate or erroneous entries made in error to the account
indicated above. I hereby authorize the financial institution/bank named above to credit and/or debit the same to
such account. CMS may assign its rights and obligations under this agreement to CMS’ designated fee-for-service
contractor. CMS may change its designated contractor at CMS’ discretion.
If payment is being made to an account controlled by a Chain Home Office, the Provider of Services hereby
acknowledges that payment to the Chain Office under these circumstances is still considered payment to the
Provider, and the Provider authorizes the forwarding of Medicare payments to the Chain Home Office.
If the account is drawn in the Physician’s or Individual Practitioner’s Name, or the Legal Business Name of the
Provider/ Supplier, the said Provider or Supplier certifies that he/she has sole control of the account referenced
above, and certifies that all arrangements between the Financial Institution and the said Provider or Supplier are
in accordance with all applicable Medicare regulations and instructions.
This authorization agreement is effective as of the signature date below and is to remain in full force and
effect until CMS has received written notification from me of its termination in such time and such manner as
to afford CMS and the Financial Institution a reasonable opportunity to act on it. CMS will continue to send the
direct deposit to the Financial Institution indicated above until notified by me that I wish to change the Financial
Institution receiving the direct deposit. If my Financial Institution information changes, I agree to submit to CMS
an updated EFT Authorization Agreement.

SIGNATURE LINE

Authorized/Delegated Official Name (Print)

Authorized/Delegated Official Telephone Number

Authorized/Delegated Official Title

Authorized/Delegated Official E-mail Address

Authorized/Delegated Official Signature (Note: Must be original signature in black or blue ink.)

Date

PRIVACY ACT ADVISORY STATEMENT

Sections 1842, 1862(b) and 1874 of title XVIII of the Social Security Act authorize the collection of this information.
The purpose of collecting this information is to authorize electronic funds transfers.
Per 42 CFR 424.510(e)(1), providers and suppliers are required to receive electronic funds transfer (EFT) at the time
of enrollment, revalidation, change of Medicare contractors or submission of an enrollment change request; and
(2) submit the CMS-588 form to receive Medicare payment via electronic funds transfer.
The information collected will be entered into system No. 09-70-0501, titled “Carrier Medicare Claims Records,”
and No. 09-70-0503, titled “Intermediary Medicare Claims Records” published in the Federal Register Privacy Act
Issuances, 1991 Comp. Vol. 1, pages 419 and 424, or as updated and republished. Disclosures of information from
this system can be found in this notice.
You should be aware that P.L. 100-503, the Computer Matching and Privacy Protection Act of 1988, permits the
government, under certain circumstances, to verify the information you provide by way of computer matches.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0626. The time required to complete this information
collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland
21244-1850.
DO NOT MAIL THIS FORM TO THIS ADDRESS.

MAILING YOUR APPLICATION TO THIS ADDRESS WILL SIGNIFICANTLY DELAY PROCESSING.

FORM CMS-588 (XX/13)

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INSTRUCTIONS FOR COMPLETING THE EFT AUTHORIZATION AGREEMENT

All EFT requests are subject to a 15-day pre-certification period in which all accounts are verified by the qualifying financial
institution before any Medicare direct deposits are made.

PART I: REASON FOR SUBMISSION
Indicate your reason for completing this form by checking the appropriate box: New EFT authorization or change to your
account information. If you are authorizing EFT payments to the home office of a chain organization of which you are a
member, you must attach a letter authorizing the contractor to make payment due the provider of service to the account
maintained by the home office of the chain organization. The letter must be signed by an authorized official of the provider of
service and an authorized official of the chain home office.

PART II: PROVIDER OR SUPPLIER INFORMATION
Line 1: Enter the provider’s/supplier’s legal business name or the name of the physician or individual practitioner, as reported
to the Internal Revenue Service (IRS). The account to which EFT payments made must exclusively bear the name of the
physician or individual practitioner, or the legal business name of the person or entity enrolled with Medicare.
NOTE: Providers/suppliers must report the legal business name provided on the IRS CP-575 form.
Line 2: Enter the chain organization’s name or the home office legal business name if different from the chain organization
name.
NOTE: Providers/suppliers must report the legal business name provided on the IRS CP-575 form.
Line 3: Enter the account holder’s practice location street address.
Line 4: Enter the account holder’s practice location city, state, and zip code.
Line 5: Enter the tax identification number as reported to the IRS. If the business is a corporation, provide the Federal
employer identification number, otherwise provide your Social Security Number.
Line 6: If issued, enter the Medicare identification number assigned by a Medicare fee-for-service contractor. If you are not
enrolled in Medicare, leave this field blank.
Line 7: Enter the 10 digit NPI number(s). The NPI is required to process this form.
NOTE: Institutional providers enter only ONE NPI.

PART III: FINANCIAL INSTITUTION INFORMATION
Line 8: Enter your Financial Institution’s name (this is the name of the bank or qualifying depository that will receive the
funds). Note: The account name to which EFT payments will be paid is to the name submitted on Part II of this form.
Line 9: Enter the financial institution’s street address.
Line 10: Enter the financial institution’s city or town, state, and zip code.
Line 11: Enter the bank or financial institutional telephone number and contact person’s name.
Line 12: Enter the bank or financial institutional nine-digit routing number, including applicable leading zeros.
Line 13: Enter the depositor’s account number, including applicable leading zeros. Select the account type.
If you do not submit this information, your EFT authorization agreement will be returned without further processing.

PART IV: CONTACT PERSON
Line 14: Enter the name and title of a contact person who can answer questions about the information submitted on this
CMS-588 form.
Line 15: Enter the contact person’s telephone number. Enter the contact person’s e-mail address.

PART V: AUTHORIZATION
Line 16: By your signature on this form you are certifying that the account is drawn in the Name of the Physician or Individual
Practitioner, or the Legal Business Name of the Provider or Supplier. The Provider or Supplier has sole control of the
account to which EFT deposits are made in accordance with all applicable Medicare regulations and instructions. All
arrangements between the Financial Institution and the said Provider or Supplier are in accordance with all applicable
Medicare regulations and instructions with the effective date of the EFT authorization. You must notify CMS regarding
any changes in the account in sufficient time to allow the contractor and the Financial Institution to act on the
changes.
The EFT authorization form must be signed and dated by the same Authorized Representative or a Delegated Official named
on the CMS-855 Medicare enrollment application which the Medicare contractor has on file. Include a telephone number where
the Authorized Representative or Delegated Official can be contacted.
Mail this form with the original signature in black or blue ink (no facsimile signatures can be accepted) to the Medicare
contractor that services your geographical area. An EFT authorization form must be submitted for each Medicare contractor to
whom you submit claims for Medicare payment. To locate the mailing address for your fee-for-service contractor, go to:
www.cms.gov/MedicareProviderSupEnroll.
FORM CMS-588 Instructions (XX/13)

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