Form Cms-588 (08/06) - Electronic Funds Transfer (Eft) Authorization Agreement - Department Of Health And Human Services Page 3
Download a blank fillable Form Cms-588 (08/06) - Electronic Funds Transfer (Eft) Authorization Agreement - Department Of Health And Human Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cms-588 (08/06) - Electronic Funds Transfer (Eft) Authorization Agreement - Department Of Health And Human Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3INSTRUCTIONS FOR COMPLETING THE EFT AUTHORIZATION AGREEMENT
All EFT requests are subject to a 15-day pre-certification period in which all accounts are verified by the qualifying
financial institution before any Medicare direct deposits are made.
PART I – REASON FOR SUBMISSION
Indicate your reason for completing this form by checking the appropriate box: New EFT authorization or change to
your account information. If you are authorizing EFT payments to the home office of a chain organization of which you are
a member, you must attach a letter authorizing the contractor to make payment due the provider of service to the
account maintained by the home office of the chain organization. The letter must be signed by an authorized official of
the provider of service and an authorized official of the chain home office.
PART II – IDENTIFICATION DATA
Line 1 – Enter the name of the physician or individual practitioner, or the legal business name of the provider/supplier
as reported to the Internal Revenue Service (IRS). The account to which must exclusively bear the name of the
physician or individual practitioner, or the legal business name of the person or entity enrolled with Medicare.
Line 2 – Enter the provider’s/supplier’s legal business name. The account to which EFT payments made must
exclusively bear the name of the physician or individual practitioner, or the legal business name of the person
or entity enrolled with Medicare.
Line 3 – Enter the chain organization’s name.
Line 4 – Enter the home office legal business name if different from the chain organization name.
Line 5 – Enter the tax identification number as reported to the IRS. If the business is a corporation, provide the Federal
employer identification number, otherwise provide your Social Security Number.
Line 6 – If issued, enter the Medicare identification number assigned by a Medicare fee-for-service contractor. If you
are not enrolled in Medicare, leave this field blank.
Line 7 – Enter the 10 digit NPI number. The NPI is required to process this form.
PART III – DEPOSITORY INFORMATION (Financial Institution)
Line 8 – Enter your depository name (this is the name of the bank or qualifying financial institution that will receive
the funds).
Line 9 – Enter the depository’s street address.
Line 10 – Enter the depository’s city, state and ZIP code.
Line 11 – Enter the bank or financial institutional telephone number.
Line 12 – Enter the depository’s contact person.
Line 13 – Enter the bank or financial institutional nine-digit routing number.
Line 14 – Enter the depositor’s account number and select the account type.
If you do not submit this information, your EFT authorization agreement will be returned without further processing.
PART IV – CONTACT PERSON
Enter the information for the contact person responsible for this EFT authorization agreement.
PART V – AUTHORIZATION
Enter the name of the CMS fee-for-service contractor in Part V who has authority to initiate credit entries.
Line 24 – By your signature on this form you are certifying that the account is drawn in the Name of the Physician
or Individual Practitioner, or the Legal Business Name of the Provider or Supplier. The Provider or Supplier has
sole control of the account to which EFT deposits are made in accordance with all applicable Medicare
regulations and instructions. All arrangements between the depository and the said Provider or Supplier are
in accordance with all applicable Medicare regulations and instructions with the effective date of the EFT
authorization. You must notify the Medicare contractor regarding any changes in the account in sufficient
time to allow the contractor and the depository to act on the changes.
The EFT authorization form must be signed and dated by the same Authorized Representative or a Delegated Official
named on the CMS-855 Medicare enrollment application which the Medicare contractor has on file.
Mail this form with the original signature (no facsimile signatures can be accepted) to the Medicare contractor that
services your geographical area. To locate the mailing address for your fee-for-service contractor, go to:
FORM CMS-588 Instructions (08/06) EF 07/2007
3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Cms-588 (05/10) - Electronic Funds Transfer (eft) Authorization Agreement - Department Of Health And Human Services
Business
Form Dhhs-2887 - Public Water Supply Regional Office Request - N.c. Department Of Health And Human Services
Legal
Form Dma-3066 - Independent Assessment Request For New Admissions - North Carolina Department Of Health And Human Services
Legal
Form Dcss 650 - Child Support Guidelines Worksheet - New Hampshire Dcss 650 Department Of Health And Human Services
Legal
Form Dss-1812 - General Authorization For Treatment And Medication - North Carolina Department Of Health And Human Services
Legal
Form Dhhs 1662 - Nursing Record Of Tuberculosis Contacts Form - U.c. Department Of Health And Human Services
Legal
Related Categories
Parent category: Business