Form Cms-588 (05/10) - Electronic Funds Transfer (Eft) Authorization Agreement - Department Of Health And Human Services Page 2
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3PART 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 fee-for-service
contractor. 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 or 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 or 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 Title
Authorized/Delegated Official E-mail Address
Authorized/Delegated Official Signature
Date
(Note: Must be original signature in black or blue ink.)
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 60 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 (05/10)
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