Form CMS-588, EFT Authorization Agreement Completed Form Examples and Samples
Explore detailed examples of completed Form CMS-588, EFT Authorization Agreement, for various use cases including medical equipment suppliers and home health care agencies. Each example features precise information about suppliers, financial institutions, and necessary authorizations needed to streamline CMS payments.
CMS-588 Example – Medical Equipment Supplier
How this form was filled:
This example demonstrates how a medical equipment supplier authorizes electronic funds transfer with CMS using Form CMS-588. It includes detailed information about the supplier, their financial institution, and required authorizations. The form is signed and dated appropriately.
Information used to fill out the document:
- Supplier Name: XYZ Medical Supplies
- Supplier Address: 456 Health Ave, Medcity, USA
- Financial Institution Name: Health Bank Corp
- Financial Institution Address: 123 Financial Rd, Banktown, USA
- Type of Depositor Account: Checking
- Depositor Routing Number: 123456789
- Depositor Account Number: 9876543210
- Authorized Official Name: Jane Smith
- Authorized Official Title: Chief Financial Officer
- Signature: Jane Smith
- Date: 03/10
What this filled form sample shows:
- Correctly filled supplier details and financial institution information
- Accurate routing and account numbers for EFT
- Properly signed and dated authorization
- Streamlined EFT setup to ensure timely CMS payments
Form specifications and details:
| Use Case: | Authorizing EFT for a medical equipment supplier |
| Year: | 2025 |
CMS-588 Example – Home Health Care Agency
How this form was filled:
This example illustrates the CMS-588 EFT Authorization Agreement form completion for a home health care agency, detailing how they set up electronic funds transfer for CMS payments.
Information used to fill out the document:
- Supplier Name: CareFirst Home Health Services
- Supplier Address: 789 Care St, Homestown, USA
- Financial Institution Name: Community Trust Bank
- Financial Institution Address: 456 Main Blvd, Financetown, USA
- Type of Depositor Account: Savings
- Depositor Routing Number: 987654321
- Depositor Account Number: 1234567890
- Authorized Official Name: David Johnson
- Authorized Official Title: Financial Director
- Signature: David Johnson
- Date: 02/05
What this filled form sample shows:
- Detailed agency information and bank details
- Clear routing and account numbers for precise EFT setup
- Properly authorized with official signature and date
- Effective enablement of CMS payments via electronic means
Form specifications and details:
| Use Case: | Authorizing EFT for a home health care agency |
| Year: | 2025 |
