Form CMS-588, EFT Authorization Agreement Instructions
This form contains 39 fields organized into 6 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Account Holder Information | ||
| Individual | CheckBox |
Check this box if you are an individual enrolling for EFT.
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| Group | CheckBox |
Check this box if you are a group enrolling for EFT.
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| Check here if EFT payment is being made to the Home Office of the Chain Organization the Home Office of the Chain Organization | CheckBox |
Check this box if the EFT payment is being made to the Home Office of the Chain Organization.
|
| PART 2: ACCOUNT HOLDER INFORMATION. Provider/Supplier/Indirect Payment Procedure (I.P.P.) Biller Legal Business Name | Text |
Enter the legal business name of the provider, supplier, or Indirect Payment Procedure (IPP) biller.
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| Chain Organization Name or Home Office Legal Business Name | Text |
Enter the legal business name of the Chain Organization or Home Office.
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| Chain Home Office number | Text |
Enter the Chain Home Office number.
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| Account Holder’s Street Address | Text |
Enter the street address of the account holder.
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| Account Holder’s Practice Location City | Text |
Enter the city of the account holder's practice location.
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| Account Holder’s Practice Location State 2 letter abbreviation | Text |
Enter the state of the account holder's practice location using a 2-letter abbreviation.
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| Account Holder’s Practice Location 5 digit Zip Code | Text |
Enter the 5-digit zip code of the account holder's practice location.
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| Tax Identification Number (T.I.N.) 12 digits | Text |
Enter the 12-digit Tax Identification Number (TIN) of the account holder.
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| Designate TIN: SSN (enrolling as an individual) OR | CheckBox |
Check this box if you are designating a Social Security Number (SSN) as the TIN for an individual enrollment.
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| E.I.N. enrolling as a group/organization/corporation | CheckBox |
Check this box if you are designating an Employer Identification Number (EIN) as the TIN for a group, organization, or corporation enrollment.
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| National Provider Identifier Number (N.P.I.) 10 digits | Text |
Enter the 10-digit National Provider Identifier (NPI) number.
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| Medicare Identification Number (if issued) 12 digits | Text |
Enter the 12-digit Medicare Identification Number, if issued.
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| Medicare Identification Number (if issued) 12 digits | Text |
Enter the 12-digit Medicare Identification Number, if issued.
|
| Authorization | ||
| PART 5: AUTHORIZATION. Authorized/Delegated Official Name (Print) | Text |
Enter the name of the authorized or delegated official, printed clearly.
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| Authorized/Delegated Official Telephone Number (including 3 digit area code) | Text |
Enter the telephone number of the authorized or delegated official, including the 3-digit area code.
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| Authorized/Delegated Official E-mail Address | Text |
Enter the email address of the authorized or delegated official.
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| Authorized/Delegated Official Signature (Note: Must be signed and dated to process.) | Signature |
This field requires the signature of the authorized or delegated official. The form cannot be processed without this signature.
|
| Authorized/Delegated Official Signature Date | Text |
Enter the date when the authorized or delegated official signed the form. This date is required to validate the signature.
|
| Contact Person Information | ||
| PART 4: CONTACT PERSON. This is the person we will contact for any questions regarding this EFT. Contact Person’s Name | Text |
Enter the name of the contact person who will be reached for any questions regarding this EFT.
|
| Contact Person’s Title | Text |
Enter the title of the contact person.
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| Contact Person’s Telephone Number (including 3 digit area code) | Text |
Enter the telephone number of the contact person, including the 3-digit area code.
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| Contact Person’s E-mail Address | Text |
Enter the email address of the contact person.
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| Financial Institution Information | ||
| PART 3: FINANCIAL INSTITUTION INFORMATION. Financial Institution’s Name | Text |
Enter the name of the financial institution where your account is held.
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| Financial Institution’s Street Address | Text |
Enter the street address of the financial institution.
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| Financial Institution’s City/Town | Text |
Enter the city or town where the financial institution is located.
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| Financial Institution’s State/Province 2 letter abbreviation | Text |
Enter the state or province of the financial institution using a 2-letter abbreviation.
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| Financial Institution’s 5 digit Zip Postal Code | Text |
Enter the 5-digit ZIP or postal code of the financial institution.
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| Financial Institution’s Telephone Number (including 3 digit area code) optional | Text |
Enter the telephone number of the financial institution, including the 3-digit area code. This field is optional.
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| Financial Institution’s Contact Person (optional) | Text |
Enter the name of a contact person at the financial institution. This field is optional.
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| Financial Institution Routing Number (must be 9 digits) | Text |
Enter the 9-digit routing number of the financial institution.
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| Provider’s/Supplier’s Account Number with Financial Institution (include all zeroes) | Text |
Enter the provider's or supplier's account number with the financial institution, including all zeroes.
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| Type of account. check one. Checking account | CheckBox |
Check this box if the account type is a checking account.
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| Savings account | CheckBox |
Check this box if the account type is a savings account.
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| Provider/Supplier Information | ||
| Medicare Identification Number (if issued) 12 digits | Text |
Enter your Medicare Identification Number, which should be 12 digits long.
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| Reason for Submission | ||
| ELECTRONIC FUNDS TRANSFER (E.F.T.) AUTHORIZATION AGREEMENT. Part 1: Reason for Submission. New E.F.T. Enrollment | CheckBox |
Check this box if you are enrolling for a new Electronic Funds Transfer (EFT) for Medicare payments.
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| Change to Current E.F.T. Enrollment (eg. account or bank changes) | CheckBox |
Check this box if you are making changes to your current EFT enrollment, such as account or bank changes.
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