Information Collection

Electronic Funds Transfer Authorization Agreement

IC 43660 under ICR 202305-0938-005 · OMB 0938-0626.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-588 Electronic Funds Transfer Authorization Agreement	Form and Instruction
CMS-588 Electronic Funds Transfer CMS-588 - Electronic Funds Transfer Form.pdf	Form and Instruction
CMS-588 Electronic Funds Transfer CMS-588 - Electronic Funds Transfer Form.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-588	Electronic Funds Transfer	CMS-588 - Electronic Funds Transfer Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Provider Enrollment, Chain and Ownership System: SORN number 09-70-0532

FR Citation: 83 FR 6591

Number of Respondents: 82,807

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	82,807	-33,026	115,833
Annual IC Time Burden (Hours)	56,037	-1,880	57,917
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.