Electronic Funds Transfer Agreement

Download and complete the CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement.

Physicians and nonphysician practitioners who are reassigning all of their payments to another entity are not required to submit the CMS-588.

Required documents:

• A voided check or confirmation of account information on bank letterhead
  • Document must contain:
  • • Provider/legal business name on the account
    • Electronic routing transit number
    • Account number
    • Account type (checking or saving)
    • Bank symbol or logo
    • Name on the EFT form and the name on the checking or savings account must match the exact legal business name as reported to the IRS or Social Security Administration.
    • Bank officer’s first and last name and signature required for confirmation that is on letterhead document
• Lending relationship letter (bank agreement to waive Medicare offsets) if applicable.

Not Acceptable:

• Deposit slip or direct deposit authorization forms
• Money market accounts
• The bank account cannot be a joint account or “doing business as” name

Related Content

• Prevent Revalidation Processing Delays
• Electronic Funds Transfer
• Electronic Funds Transfer Form and Instructions

Updated 11/12/2021