Form Cms-588 - Electronic Funds Transfer (Eft) Authorization Agreement
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No. 0938-0626
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Expires: 01/2020
CENTERS FOR MEDICARE & MEDICAID SERVICES
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT
PART I: REASON FOR SUBMISSION
Reason for Submission:
New EFT Enrollment
Check here if EFT payment is being made to
the Home Office of the Chain Organization
Individual
Group
(Attach letter Authorizing EFT payment to
Change to Current EFT Enrollment
Chain Home Office)
(e.g. account or bank changes)
Cancel EFT Enrollment
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: ACCOUNT HOLDER INFORMATION
Provider/Supplier/Indirect Payment Procedure (IPP) Biller 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 (TIN)
Designate TIN
SSN (enrolling as an individual) OR
EIN (enrolling as a group/organization/corporation
Medicare Identification Number (if issued)
Health Plan Identifier (HPID) or Other Entity Identifier (OEID) (IPP Entities Only)
National Provider Identifier (NPI)
National Provider Identifier (NPI)
National Provider Identifier (NPI)
PART III: FINANCIAL INSTITUTION INFORMATION
Financial Institution’s Name
Financial Institution’s Street Address
Financial Institution’s City/Town
Financial Institution’s State/Province
Financial Institution’s Zip Postal Code
Financial Institution’s Telephone Number
Financial Institution’s Contact Person (optional)
Financial Institution Routing Number (must be 9 digits)
Provider’s/Supplier’s/IPP Entity’s Account Number with Financial Institution (include all zeroes)
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. 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 (01/17)
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Parent category: Medical