Get Cms 588 Form 2020-2024

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 information collection. If you have any comments concerning the accuracy of the time estimate s or suggestions for improving this form please write to CMS Attn PRA Reports Clearance Officer 7500 Security Boulevard Baltimore Maryland 21244-1850. Note The account name to which EFT payments will be paid is to the name submitted on Part II of this form. Line 9 Enter the financial institution s street address. If my Financial Institution information changes I agree to submit to CMS an updated EFT Authorization Agreement. SIGNATURE LINE Authorized/Delegated Official Name Print Date PRIVACY ACT ADVISORY STATEMENT Sections 1842 1862 b and 1874 of title XVIII of the Social Security Act authorize the collection of this information. The purpose of collecting this information is to authorize electronic funds transfers. Per 42 CFR 424. 510 e 1 providers and suppliers are required to receive electronic funds transfer EFT at the time of enrollment revalidation change of Medicare contractors or submission of an enrollment change request and 2 submit the CMS-588 form to receive Medicare payment via electronic funds transfer. SIGNATURE LINE Authorized/Delegated Official Name Print Date PRIVACY ACT ADVISORY STATEMENT Sections 1842 1862 b and 1874 of title XVIII of the Social Security Act authorize the collection of this information. The purpose of collecting this information is to authorize electronic funds transfers. Per 42 CFR 424. 510 e 1 providers and suppliers are required to receive electronic funds transfer EFT at the time of enrollment revalidation change of Medicare contractors or submission of an enrollment change request and 2 submit the CMS-588 form to receive Medicare payment via electronic funds transfer. The information collected will be entered into system No. 09-70-0501 titled Carrier Medicare Claims Records and No. 09-70-0503 titled Intermediary Medicare Claims Records published in the Federal Register Privacy Act Issuances 1991 Comp. Vol. 1 pages 419 and 424 or as updated and republished. Disclosures of information from this system can be found in this notice. Include a telephone number where the Authorized Representative or Delegated Official can be contacted. Mail this form with the original signature in black or blue ink no facsimile signatures can be accepted to the Medicare contractor that services your geographical area. An EFT authorization form must be submitted for each Medicare contractor to whom you submit claims for Medicare payment.