Form Cms-588 (05/10) - Electronic Funds Transfer (Eft) Authorization Agreement - Department Of Health And Human Services

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0626
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT
PART I: REASON FOR SUbMISSION
Reason for Submission:
Check here if EFT payment is being made to
New EFT Authorization
the Home Office of Chain
Revision to Current Authorization
(Attach letter Authorizing EFT payment to
(e.g. account or bank changes)
Chain Home Office)
Since your last EFT authorization agreement submission, have you had a:
Change of Ownership, and/or
Change of Practice Location?
If you checked either a change of ownership or change of practice location above, 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: PROvIDER OR SUPPLIER INFORMATION
Provider/Supplier Legal Business Name
Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name)
Account Holder’s Street Address
Account Holder’s City
Account Holder’s State
Account Holder’s Zip Code
Tax Identification Number: (designate
SSN or
EIN)
Medicare Identification Number (if issued)
National Provider Identifier (NPI)
PART III: FINANCIAL INSTITUTION INFORMATION
Financial Institution Name
Financial Institution City/Town
Financial Institution State
Financial Institution Telephone Number
Financial Institution Contact Person
Financial Institution Routing Transit Number (nine digit)
Depositor Account Number
Type of Account (check one)
Checking Account
Savings Account
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.
PART Iv: CONTACT PERSON
Contact Person’s Name
Contact Person’s Title
Contact Person’s Telephone Number
Contact Person’s E-mail Address
FORM CMS-588 (05/10)
1

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