PART V – AUTHORIZATION
I hereby authorize the Centers for Medicare & Medicaid Services fee-for-service contractor, ______________________
_______________________, hereinafter called the CONTRACTOR, to initiate credit entries, and in accordance with 31
CFR part 210.6(f) initiate adjustments for any credit entries made in error to the account indicated above. I hereby
authorize the financial institution/bank named above, hereinafter called the DEPOSITORY, to credit and/or debit
the same to such account.
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 DEPOSITORY 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 the CONTRACTOR has received written notification from me of its termination in such time and such manner
as to afford the CONTRACTOR and the DEPOSITORY a reasonable opportunity to act on it. The CONTACTOR will
continue to send the direct deposit to the DEPOSITORY indicated above until notified by me that I wish to change
the DEPOSITORY receiving the direct deposit. If my DEPOSITORY information changes, I agree to submit to the
CONTRACTOR an updated EFT Authorization Agreement.
Signature Line
Authorized/Delegated Official Name
___________________________________________________________________
(Print)
Authorized/Delegated Official Title __________________________________________________________________________
Authorized/Delegated Official Signature ________________________________________________ Date _______________
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.
Under 31 U.S.C. 3332(f)(1), all Federal payments, including Medicare payments to providers and suppliers, shall be
made by 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 (08/06) EF 07/2007
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