Electronic Funds Transfer Authorization Agreement

Electronic Funds Transfer Authorization Agreement (CMS-588)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Electronic Funds Transfer Authorization Agreement	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:

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 %

	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

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.