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Get MD CMS-5510 2005

No. 11636 January 2013 AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS OMB No.: 1510-0059 Expires: 01/31/2014 Centers for Medicare & Medicaid Services (AGENCY NAME) Paperwork Reduction Act/Privacy Act Statement The information requested on this form is required under various provisions of title 15 USC Chapter 41, 12 CFR 205, and 31 CFR 202 and 206, for the purpose of authorizing the Department of Treasury to designate financial institutions to electronically collect payments from your acc.

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