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CHANGE EXISTING PROVIDER ENROLLMENT INFORMATION

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Electronic Funds Transfer Form and Instructions

To initiate the EFT process, you will need to complete the Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588). By signing the CMS-588 form, you are certifying the account is in compliance with the CMS instructions. The agreement must be signed by the authorized or delegated official who signed the Medicare enrollment application. If the appropriate CMS-855 Medicare Enrollment Application form is not on file in our office, the provider must submit one before the EFT can be established.

Submitting the EFT Form

Return completed EFT forms to the appropriate office location so that processing can be finalized.

CMS-588 EFT (1/17) Completion Tips for Sole Proprietors, Sole Owners, Clinic/Groups, Organizations and Suppliers

Note: Providers reassigning all benefits to a group, do not need to complete the CMS-588.

Section General Guidelines
Part I: Reason for Submission Mark all that apply:
  • New or Change EFT information ‒ attach a copy of a voided check or bank confirmation letter
  • Chain Organizations ‒ attach letter authorizing EFT payment to the chain home office
Part II: Account Holder Information Complete all fields:
  • Providers/Suppliers/IPP billers must report the legal business name provided on the IRS document
  • Sole proprietors using EIN indicate EIN for designated TIN
Part III: Financial Institution Information Complete all fields:
  • Routing number is nine digits long
  • Entire account number including applicable leading zeros
Part IV: Contact Information Complete all fields:
  • Enter title of contact person
Part V: Authorization (Signature Line) Complete all fields:
  • Sign and date by sole proprietor or authorized/delegated official of a group
  • Enter title of authorized/delegated official

Reminder: To avoid possible hold on payments or deactivation of billing privileges, respond timely to additional information request for the incomplete/inaccurate CMS-588 form.

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Revised 4/22/2019


Electronic Funds Transfer Form and Instructions
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