Loading
Form preview picture

Get CMS-588 2020-2024

Indicate your reason for completing this form by checking the appropriate box New EFT enrollment change to your EFT enrollment account information or cancellation of your EFT enrollment. Zeros. Select the account type. If you do not submit this information your EFT authorization agreement will be returned without further processing. CMS-588 form. Line 16 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 person or entity. To locate the mailing address for your fee-for-service contractor go to www. cms. gov/MedicareProviderSupEnroll. Form CMS-588 Instructions 09/13. 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. Note The account name to which EFT payments will be paid is to the name submitted on Part II of this form. Line 9 Enter the financial institution s street address. If my Financial Institution information changes I agree to submit to CMS an updated EFT Authorization Agreement. SIGNATURE LINE Authorized/Delegated Official Name Print 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. Per 42 CFR 424. 510 e 1 providers and suppliers are required to receive electronic funds transfer EFT at the time of enrollment revalidation change of Medicare contractors or submission of an enrollment change request and 2 submit the CMS-588 form to receive Medicare payment via electronic funds transfer. SIGNATURE LINE Authorized/Delegated Official Name Print 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. Per 42 CFR 424. 510 e 1 providers and suppliers are required to receive electronic funds transfer EFT at the time of enrollment revalidation change of Medicare contractors or submission of an enrollment change request and 2 submit the CMS-588 form to receive Medicare payment via 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. Include a telephone number where the Authorized Representative or Delegated Official can be contacted. Mail this form with the original signature in black or blue ink no facsimile signatures can be accepted to the Medicare contractor that services your geographical area. An EFT authorization form must be submitted for each Medicare contractor to whom you submit claims for Medicare payment.

How It Works

eft rating
4.8Satisfied
57 votes

Tips on how to fill out, edit and sign When form eftps online

How to fill out and sign Are form eftps online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Business, tax, legal and other documents need an advanced level of protection and compliance with the law. Our forms are updated on a regular basis according to the latest amendments in legislation. Additionally, with us, all of the details you include in the CMS-588 is well-protected from loss or damage through cutting-edge file encryption.

The tips below will help you fill in CMS-588 quickly and easily:

  1. Open the template in our full-fledged online editing tool by clicking Get form.
  2. Complete the requested fields which are yellow-colored.
  3. Click the green arrow with the inscription Next to jump from box to box.
  4. Use the e-signature solution to e-sign the document.
  5. Insert the relevant date.
  6. Check the entire e-document to make sure you have not skipped anything important.
  7. Hit Done and save your new template.

Our solution allows you to take the whole process of executing legal papers online. As a result, you save hours (if not days or even weeks) and get rid of additional expenses. From now on, fill out CMS-588 from the comfort of your home, place of work, as well as on the go.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing how form eftps

Are you bored of lengthy instructions and puzzling inquiries in formal documents? Using our simple video guide and online editor will help you fill in and sign Form without the usual frustration.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to eft form

  • eft from
  • form 588
  • ach authorization form template
  • cms form 588 printable
  • eft payment form
  • eft format
  • eft forms
  • cms form 588
  • electronic fund transfer form
  • cms form 588 eft agreement
  • eft enrollment
  • eft electronic funds transfer form
  • vendor eft authorization form template
  • cms 588 eft agreement
  • cms 588 eft
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.