If the suppliers financial institution does notwill not participate in proposed eft. Form approved omb the paper enrollment application process e. An electronic funds transfer authorization agreement eft form cms 588 must be included with your application request. Medicare bank letter template physician practice specialists. Suppliers revalidating should submit the necessary cms 588 forms if not already enrolled to receive payments through eft. Aarp health insurance plans pdf download medicare replacement pdf download medicare benefits pdf download medicare part b pdf download cms 588a form mailing address. If you dont know the address for your carrier, you can look at your medicare summary notice msn. Electronic funds transfer authorization agreement cms588. Profit status p or np mdpcp application id number mdpcpxxxx attach signed bank letter or voided check send hard copy back to cmmi via overnight mail with tracking.
Cms588 form steps download, print, and complete form including 9digit tinein in the top righthand corner, write in. Cms 588 form electronic funds transfer eft aytorization. Hard copy forms may be available from intermediaries, carriers, state agencies, local social security offices or end stage renal. Participants agree to accept assignment for all covered services provided to.
Cms requires that all providers enrolling or changing existing enrollment information must use eft. The applicant completes and submits a cms 855a enrollment application and all supporting documentation to its feeforservice contractor. Cms requires that all providerssuppliers enrolling in medicare or making changes to their enrollment file use electronic funds transfer eft. Electronic funds transfer eft authorization agreement. Department of health and human services form approved centers. Youll find the address for form submission in the instructions. Mar 18, 2018 medicare bank letter template download here cms 588 eft agreement download here.
Form 588 2019 side 1 taxable year 2020 nonresident withholding waiver request california form 588 part i withholding agent information part ii requester information part iii type of income subject to withholding business name business name ssn or itin ssn or itin fein fein ca corp no. Eft enrollment does not constitute enrollment as a provider or supplier in the. Electronic funds transfer eft authorization agreement cms588. These instructions were written to assist ihs and tribally owned and operated facilities with completing the cms 855s application for initial enrollment in the durable medical equipment, prosthetics, orthotics and supplies dmepos program. It must contain a handwritten signature stamped signatures will not. Since your last eft authorization agreement submission, have you had a. Attach a voided check or your account information on bank letterhead. Getting ready for the maryland primary care program. A pdf copy of the form has also been attached to this email. Medicare providersupplier enrollment applications the medicare enrollment application cms 855 or internetbased provider enrollment, chain and ownership system pecos is an office of management and budget approved form and is available in pdf fillable format. Cms 460 medicare participating physician or supplier agreement. Instruction guide to completing the initial cms 855s for ihs. Providers and suppliers must use the revised cms588 form electronic funds transfer.
Medicare cms 588 4 cms medicare cms 855a attachment a checklist 4 0 scsi 009 medicare cms 8558 4 0 r071 cms 8551 4 cms 8550 40ro 20 cms created symed name. Cms requires all providers that are enrolling in medicare part a, revalidating, or when the ein, payto address or lbn to their file is being changed, must complete the eft. Aarp health insurance plans pdf download medicare replacement pdf download medicare benefits pdf download medicare part b pdf download cms form 588 download. Medicare enrollment updates arnall golden gregory llp. Sign, fax and printable from pc, ipad, tablet or mobile. This format allows a user to complete an application using adobe acrobat and save this information on their personal computer or. The cms 460 form participating provider agreement and cms 588 form electronic transfer funds authorization. By your signature on this form you are certifying that the account is drawn in the name of the physician or individual. Cms 588 eft form instructions electronic funds transfer eft deposits your medicare payments directly into your bank account. Change to current eft enrollment since your last eft authorization agreement submission, have you had a. Complete an enrollment form with the original signature of your authorized representative.
Dec 2, 20 medicaid services cms relating to medicare provider and supplier enrollment. The eft form cms588 authorization agreement for electronic funds transfer eft is used to direct deposit your. May 11, 2012 the cp 575 may be requested by the cms external user services eus help desk, for verification, when the authorized official ao of the provider or supplier organization registers for internetbased pecos access. A federal government website managed and paid for by the u. Palmetto gba national supplier clearinghouse the cms 588 form.
The cms 588 pdf, 112 kb form may be downloaded from the cms website. Many cms program related forms are available in portable document format pdf. Sep, 2017 form cms588 or revisions to an existing cmsform 588, send the aco overview of cms. Fill out the patient request for medical payment form cms 1490s. Aarp medicarerx plans united healthcare pdf download. All eft requests are subject to a 15day precertification period. Follow the instructions on the second page to submit the form to your carrier. Access and download the cms 588 eft authorization agreement form here. On the top righthand corner of the form, please write whether your organization is profit p or nonprofit np. Copy of irs generated documentation confirming legal business name and tax identification number of entity in section 5, 7, or 8. Medicare administrative contractors will accept both the current and revised versions of the cms588 through december 31, 2017. Medicare administrative contractors will accept both the current and revised versions of the cms 588 through december 31, 2017.
Cms588 electronic funds transfer eft eft is a form of direct deposit that allows the transfer of medicare payments directly from a medicare contractors bank to a providers bank account. Jun 26, 2010 all applications for initial provider enrollment require that form cms588, electronic funds transfer eft authorization agreement, be included with the application. Below the profit status in the top righthand corner of the form, write mdpcp. Electronic funds transfer eft deposits your medicare payments directly into your bank account. Use form 588, nonresident withholding waiver request, to request a waiver from withholding on payments of california source income to nonresident payees. The eft form cms 588 authorization agreement for electronic funds transfer eft is used to direct deposit your medicare payments into your bank account. Providers and suppliers must use the revised cms 588 form electronic funds transfer. Do not use form 588 to request a waiver if you are a foreign nonu. Practitioner, or the legal business name of the person or entity. Established providers who are not already receiving payment via eft, and who are reporting any change to their 855 enrollment information, must submit form cms588 to initiate. Dec 04, 2017 change to your enrollment information will require you to submit a cms588 form.
Please be sure to reach out if you have any questions about this requirement or need assistance completing the. Clinics and group practices who are enrolled in the medicare program, but have not submitted the cms 855b since 2003, are required to submit a medicare enrollment application i. Form cms588 electronic funds transfer eft authorization agreement. Completed cms 588 electronic funds transfer eft agreement and a letter of verification from the bank. August 2015 appendix b application reference table for initial applicants. National supplier clearinghouse the cms 588 form palmetto gba. Please be sure to reach out if you have any questions about this requirement or need assistance completing the medicare enrollment process. Instruction guide to completing the initial cms 855s for. An electronic funds transfer authorization agreement eft form cms588 must be included with your application request. Fl dcwnload selected close medicare c medicare cms r40r112012 20 ate 4 or032012 medicare cms form 0 4 medicare cms hardship.