Form Cms-588 (08/06) - Electronic Funds Transfer (Eft) Authorization Agreement - Department Of Health And Human Services
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1
2
3DEPARTMENT 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
K
Reason for Submission:
New EFT Authorization
K
Revision to Current Authorization
(e.g. account or bank changes)
K
Chain Home Office:
Check here if EFT payment is being made to the Home Office of Chain
(Attach letter Authorizing EFT payment to Chain Home Office)
Organization
PART II – PROVIDER OR SUPPLIER INFORMATION
Name _____________________________________________________________________________________________________
Provider/Supplier Legal Business Name _______________________________________________________________________
___________________________________________________________________________________________________________
Chain Organization Name___________________________________________________________________________________
Home Office Legal Business Name
_____________________________________
(if different from Chain Organization Name)
___________________________________________________________________________________________________________
K
K
Tax Identification Number:
___ ___ ___ ___ ___ ___ ___ ___ ___
(Designate SSN
or EIN
)
Medicare Identification Number
______________________________________________________________________
(if issued)
National Provider Identifier (NPI) ____________________________________________________________________________
PART III – DEPOSITORY INFORMATION (Financial Institution)
Depository Name ___________________________________________________________________________________________
Street Address _____________________________________________________________________________________________
City __________________________________________________State ________________Zip Code _______________________
Depository Telephone Number ______________________________________________________________________________
Depository Contact Person __________________________________________________________________________________
Depository Routing Transit Number
___ ___ ___ ___ ___ ___ ___ ___ ___
(nine digit)
Depositor Account Number _________________________________________________________________________________
K
K
Type of Account
Checking Account
Savings Account
(check one)
Please include a voided check or deposit slip or confirmation of account information on bank letterhead. When
submitting the documentation, it should contain the name on the account, electronic routing transit number,
account number and type, and the bank officer’s name signature. This information will be used to verify your
account number.
PART IV – CONTACT PERSON
First Name
Middle Initial
Last Name
Telephone Number
Fax Number
(if applicable)
Address Line 1
(Street Name and Number)
Address Line 2
(Suite, Room, etc.)
City/Town
State
ZIP Code + 4
E-mail Address
FORM CMS-588 (08/06) EF 07/2007
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