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 - 0938-0626 - Final.docx Supporting Statement A	2020-11-30

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: 201912-0938-021
Status: Active	Previous ICR Reference No: 201609-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI - 588
Title: Electronic Funds Transfer Authorization Agreement (CMS-588)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/01/2020
	Date Received in OIRA: 01/27/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	36 Months From Approved	11/30/2020
Responses	115,833	0	45,807
Time Burden (Hours)	57,917	0	22,906
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 3332(f)(1) Name of Law: Required Direct Deposit
   US Code: 31 USC 7701(c) Name of Law: Tax Payer Identification Number
  

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:
	84 FR 50453	09/25/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 2136	01/14/2020
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	115,833	45,807	0	0	70,026	0
Annual Time Burden (Hours)	57,917	22,906	0	0	35,011	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: No

Burden Reduction Due to:

Short Statement: The total individual hour burden associated with this information collection is approximately 0.5 hours (30 minutes) per EFT form. The burden increased based on the number of respondents. The difference in respondents is 70,026 (115,833 minus 45,807). The burden hours increased 70,026 hours (57,917 hours minus 22,906 hours). The burden hour increase is due to the significantly higher number of respondents than reported in the prior revision. Previously, it was reported that 45,807 respondents completed the EFT authorization, a number also obtained from PECOS. This shows a clear increase in the number of respondents, and therefore the number of burden hours. The prior revision’s respondents were also exact processing figures from the PECOS system.

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Annual Cost to Federal Government: $0

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

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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: 01/27/2020

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