Form CMS-588 Electronic Funds Transfer

INSTRUCTIONS FOR COMPLETING THE EFT AUTHORIZATION AGREEMENT
All EFT requests are subject to a 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 enrollment or change
to your EFT enrollment 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.
NOTE: If you have had either a change of ownership or change of practice location, 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: ACCOUNT HOLDER INFORMATION

• 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 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. Physicians and
individual practitioners who have granted a Medicare-enrolled provider or supplier the right to receive payments
for all of their services, is not required to complete this form. The account holder information should be of the
person or entity receiving the reassigned benefits (e.g., Medicare Identification Number, Authorized/Delegated
Official signature).
• Enter the Chain Home Office (CHO) legal business name. A CHO is an entity that provides centralized
management and administrative services to the providers or suppliers under common ownership and common
control, such as centralized accounting, purchasing, personnel services, management direction and control, and
other similar services.
NOTE: Providers/suppliers must report the legal business name provided on the IRS CP-575 form.
• Enter the account holder’s street address.
NOTE: Do Not Include PO Boxes.
• Enter the account holder’s city, state, and zip code.
• Enter the tax identification number as reported to the IRS. If the business is a group, organization or corporation,
provide the Federal employer identification number. If enrolling as an individual provide your Social Security
Number.
• Enter the 10 digit NPI number. The NPI is required to process this form.
• A provider/supplier may only have one EFT account per enrollment.
• If issued, enter the Medicare identification number assigned by a Medicare Administrative Contractor (MAC).
If you are not enrolled in Medicare, leave this field blank. If more than one Medicare identification number is
attached to this NPI, include the Medicare identification numbers on this form.
NOTE: Institutional providers enter only ONE Medicare Identification Number (if issued).

Form CMS-588 Instructions (Rev: 12/2020)

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PART III: FINANCIAL INSTITUTION INFORMATION

• 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.
NOTE: Supporting bank documents must be in the provider’s/supplier’s/entity’s legal business name only.
• Enter your Financial Institution’s name (this is the name of the bank or qualifying depository that will receive the
funds).
NOTE: The Financial Institution’s name must be the Legal Business Name on the account, electronic routing transit
number and type.
NOTE: The account name to which EFT payments will be paid is to the name submitted on Part II of this form.
• Enter the financial institution’s street address.
NOTE: Do Not Include PO Boxes.
• Enter the financial institution’s city or town, state or province, and zip/postal code.
• Enter the bank or financial institutional telephone number and contact person’s name.
• Enter the bank or financial institutional nine-digit routing number, including applicable leading zeros.
• Enter the provider’s/supplier’s account number with the financial institution, including applicable leading zeros.
Select the account type.
NOTE: Supporting bank documents must be in the provider’s/supplier’s/entity’s legal business name only.

PART IV: CONTACT PERSON

• Enter the name and title of a contact person who can answer questions about the information submitted on this
CMS-588 form.
• Enter the contact person’s telephone number. Enter the contact person’s e-mail address.

PART V: AUTHORIZATION

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 person or entity. The person or entity 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 person or entity 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.
Upload this form to PECOS or mail this form 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 Medicare Administrative Contractor fee-for-service contractor, go
to: CMS.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/.

Form CMS-588 Instructions (Rev: 12/2020)

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Form Approved
OMB No. 0938-0626
Expires XX/20XX

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

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT
PART I: REASON FOR SUBMISSION
Reason for Submission:
New EFT Enrollment
Individual
Group

Check here if EFT payment is being made to
the Chain Home Office
(Attach letter Authorizing EFT payment to
Chain Home Office)

Change to Current EFT Enrollment
(e.g. account or bank changes)

PART II: ACCOUNT HOLDER INFORMATION
Provider/Supplier Legal Business Name (If individual, please provide first name, middle initial, last name, and suffix)
Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name)

Chain Home Office number

Account Holder’s Street Address (Do Not Include PO Boxes.)
Account Holder’s City
Tax Identification Number (TIN)

Account Holder’s State

Account Holder’s Zip Code

Designate TIN:
SSN (enrolling as an individual) OR
EIN (enrolling as a group/organization/corporation

National Provider Identifier Number (NPI)

Medicare Identification Number (if issued)

Medicare Identification Number (if issued)

Medicare Identification Number (if issued)

PART III: FINANCIAL INSTITUTION INFORMATION
Financial Institution’s Name
Financial Institution’s Street Address (Do Not Include PO Boxes.)
Financial Institution’s City/Town

Financial Institution’s State/Province

Financial Institution’s Zip Postal Code

Financial Institution’s Telephone Number (optional)

Financial Institution’s Contact Person (optional)

Financial Institution Routing Transit Number (must be 9 digits)

Provider’s/Supplier’s Depositor Account Number with Financial Institution (include all zeroes)

Type of Account (check one)

Checking Account

Savings Account

NOTE: Starter checks are not acceptable for EFT confirmations.
PLEASE NOTE: In accordance with section 1104 of the Affordable Care Act, enrollment of electronic fund transfer
(EFT) is for electronic fund transfer authorization only. EFT enrollment does not constitute enrollment as a provider
or supplier in the Medicare program.

Form CMS-588 (Rev: 12/2020)

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PART IV: CONTACT PERSON
This is the person we will contact for any questions regarding this EFT.
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 Medicare
Administrative Contractor (MAC). 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/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/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 E-mail Address (optional)

Authorized/Delegated Official Signature (Note: Must be signed and dated to process.)

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 30 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 (Rev: 12/2020)

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