Electronic Funds Transfer

Electronic Funds Transfer Form and Instructions

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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 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.

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Submitting the EFT Form

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

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CMS-588 EFT Completion Tips for Part A Institutional Providers, Home Health Agencies, Hospice or Federal Qualified Health Centers

Section General Guidelines
Part I: Reason for Submission Mark all that apply.
  • New, Change or Revalidation 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 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 authorized/delegated official
  • Enter title of authorized/delegated official
Supporting Documentation Chain Home Ownership letter (if applicable)
  • Requires signature of provider and chain home office authorized officials

Voided Check or Bank Confirmation Letter

Void Check
  • Account holder LBN must be listed first
  • Cannot be a joint account
  • Starter checks or deposit slips are not acceptable
Bank Confirmation Letter must include:
  • Bank letterhead
  • Bank officer’s name and signature
  • Account holder LBN, checking or savings account type, electronic routing transit number and account number


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.

Revised 4/14/2021

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS

J6 Mailing Address:

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Interactive Voice Response:

877-908-9499

Contact Enrollment:

877-908-8476

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. CT

Form(s) you'll need:

Enrollment Forms

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS

JK Mailing Address:

National Government Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149

Interactive Voice Response:

877-869-6504

Contact Enrollment:

888-379-3807

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. ET

Form(s) you'll need:

Enrollment Forms

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS

J6 Mailing Address:

National Government Services, Inc.
P.O. Box 6474
Indianapolis, IN 46206-6474

Contact Enrollment:

855-834-5596

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. CT
9:00 a.m.–5:00 p.m. ET

*Closed for training on the 2nd and 4th Friday of the month
12:00 p.m.-4:00 p.m. ET
11:00 a.m.-3:00 p.m. CT

Form(s) you'll need:

CMS-855A - Medicare Enrollment Application form for Institutional Providers
CMS-588 - Electronic Funds Transfer (EFT) Authorization Agreement form

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS

JK Mailing Address:

National Government Services, Inc.
P.O. Box 7149
Indianapolis, IN 46206-7149

Contact Enrollment:

855-593-8047

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. ET

*Closed for training on the 2nd and 4th Friday of the month
12:00 p.m.-4:00 p.m. ET

Form(s) you'll need:

CMS-855A - Medicare Enrollment Application form for Institutional Providers
CMS-588 - Electronic Funds Transfer (EFT) Authorization Agreement form