Electronic Funds Transfer Authorization Agreement (CMS-588)

Forms and Documents

Document Name	Status
Form CMS-588 Electronic Funds Transfer Authorization Agreement Form and Instruction	Modified
CMS-588 - Supporting Statement - Final clean.docx Supporting Statement A	2017-01-24

IC Document Collections

IC ID	Document Title	Status
43660	Electronic Funds Transfer Authorization Agreement Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0626	ICR Reference No: 201609-0938-005
Status: Historical Active	Previous ICR Reference No: 201305-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: 19637
Title: Electronic Funds Transfer Authorization Agreement (CMS-588)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/30/2017
	Date Received in OIRA: 09/16/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved	01/31/2017
Responses	45,807	0	94,000
Time Burden (Hours)	22,906	0	23,500
Cost Burden (Dollars)	0	0	0

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Abstract: The primary function of the Electronic Funds Transfer Authorization Agreement (CMS 588) is to gather information from a provider/supplier to establish an electronic payment process. The legal authority to collect this information is found in Section 1815(a) of the Social Security Act. This section provides authority for the Secretary of Health and Human Services to pay providers/suppliers of Medicare services. Under 31 U.S.C. 3332(f)(1), all Federal payments, including Medicare payments to providers and suppliers, shall be made by electronic funds transfer. 31 U.S.C. 7701 (c) requires that any person or entity doing business with the Federal Government must provide their Tax Identification Number (TIN). Goal of the Provider/Supplier Enrollment Application Revisions The goal of evaluating and revising the CMS 588 agreement is to renew the data collection. Due to previous revisions (2006 and 2009), this form is user friendly and concise. Only two minor revisions for systems requirements will be made at this time, specifically adding a street address line for the location of the financial institution and adding an additional National Provider Identification (NPI) number collection field for those providers/suppliers who have more than one NPI.

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Authorizing Statute(s): US Code: 31 USC 7701(c) Name of Law: Tax Payer Identification Number
   US Code: 31 USC 3332(f)(1) Name of Law: Required Direct Deposit
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 38186	06/13/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 62741	09/12/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Electronic Funds Transfer Authorization Agreement	CMS-588	Electronic Funds Transfer

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	45,807	94,000	0	-48,193	0	0
Annual Time Burden (Hours)	22,906	23,500	0	-594	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The total individual hour burden associated with this information collection is approximately 0.5 hours (30 minutes) per EFT form. The burden decreased based on improved technology collection regarding number of respondents and systems reporting techniques. The total number of respondents is 45,807 for both initial enrollments and reporting changes of EFT information. The new total annual hour burden associated with this information collection is approximately 22,543 hours for initial enrollments and 363 hours for changes of information, for a total of 22,906 hours. The cost burden increase is due to the revised wage amounts and the change in how the amount is calculated. The new cost burden is approximately $1,952,094 for initial enrollments and $31,349 for reporting changes of EFT information for a total of $1,983,443.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/16/2016

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