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 informat....
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How to fill out the CMS-588 online
The CMS-588 form serves as an Electronic Funds Transfer (EFT) authorization agreement for Medicare payments. This guide provides you with step-by-step instructions on how to complete the CMS-588 online, ensuring that your information is accurately submitted.
Follow the steps to fill out the CMS-588 online successfully.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Indicate your reason for submission by checking the appropriate box in Part I. Choose between new EFT enrollment, change to current enrollment, or revalidation. If applicable, attach the required authorizing letter for payments to a chain organization.
- In Part II, fill in the account holder's information. Provide the legal business name of the provider or supplier as reported to the IRS, the chain organization name if different, the street address, city, state, and zip code.
- Enter the tax identification number, specifying whether it is an individual or employer identification number, and include the National Provider Identifier (NPI) number.
- If applicable, include the Medicare identification number assigned by a Medicare Administrative Contractor in the designated field.
- Part III requires you to provide financial institution information. Enter the name, address, city, state, postal code, and phone number of the financial institution.
- Input the financial institution's nine-digit routing number and your provider's account number. Ensure that the account type is marked as either checking or savings.
- In Part IV, provide the contact person's name, title, telephone number, and email address for any questions regarding the submitted information.
- Part V requires a signature from the authorized representative or a delegated official. Print their name, title, phone number, and email address. Ensure this section is signed and dated.
- After completing all sections, save your changes, and choose to download, print, or share the completed form as needed.
Complete your CMS-588 form online today to ensure timely processing of your Medicare payments.
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