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 that 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 (CMS-855). If the appropriate CMS-855 Medicare enrollment 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 Completion Tips for Part A Institutional Providers, Home Health Agencies, Hospice or Federal Qualified Health Centers
|Part I: Reason for Submission||Mark all that apply.
|Part II: Account Holder Information||Complete all fields.
|PART III: Financial Institution Information||Complete all fields.
|PART IV: Contact Information||Complete all fields.
Authorization (Signature Line)
|Complete all fields.
|Supporting Documentation||Chain Home Ownership letter (if applicable)
Voided Check or Bank Confirmation LetterVoid Check
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.