CMS 588 EFT Form Instructions - JE Part A

Indicate the reason for completing the form:

1. New EFT Enrollment- Adding EFT information for the first time.
   • Answer if Individual or Group
2. Change to Current EFT Enrollment- Change to the banking information from what is currently on file with Medicare.

If you are authorizing EFT payments to a Chain Home Office:

1. A letter must be attached authorizing the contractor to make payments due to the provider to the bank account that is maintained by the chain home office.
2. The letter must be signed by the authorized official of the provider authorizing the service and the authorized official of the chain home office.

Enter the provider/supplier's legal business name as reported to the IRS:

1. For an organization, group, or sole owned corporation/ incorporated individual; the Legal Business name must be provided in this section. It must match the CP-575.
2. Sole Proprietors (non-incorporated), with or without and EIN must enter the provider's legal name as established with the Social Security Administration (SSA) in this section.

Enter the chain organization's name or home office legal business name (if different from the chain organization's name)

Do not list the enrollee's Doing Business as Name (DBA) in in this field.

Note: If the provider is not a member of a chain organization, the account to which the payments are made must exclusively bear the name of the physician, individual practitioner, or legal business name of the person or entity enrolled in Medicare.

Enter the account holder's physical street address, city, state, and zip code.

This cannot be a PO Box.

Enter the tax identification number as reported to the IRS.

1. Corporations/Organizations need to enter the Federal Employer Identification Number (EIN).
2. Sole Proprietors (non-incorporated) with or without an EIN need to enter their Social Security Number (SSN).

Enter the Medicare Identification Number assigned by the contractor, if one has been issued. This is also referred to as a provider enrollment access number (PTAN).

Enter the 10 digit NPI number.

1. For group's/organizations, enter the group's NPI number (type 2).
2. For sole proprietors, this should be the provider's individual NPI number (type 1).

Enter the Financial Institution's Name (bank or other qualifying depository) to where the funds will be deposited.

Enter the financial institution's physical address (cannot be a PO Box), city, state, and zip code.

Enter the telephone number for the bank/financial institution.

Enter the name of the contact person at the bank/financial institution, who will be able to answer questions Medicare may have regarding the account or set-up of the account. This should not be the contact person for the enrollee, but rather a representative from the bank itself.

Enter the bank/financial institution's nine-digit routing number, including applicable leading zeros. This must match exactly as found on the voided check or bank letter.

The routing number cannot begin with a 5.

Enter the depositor's account number including applicable leading zeros. This must match exactly as found on the voided check or bank letter.

Check the account type (checking or savings) that the EFT payments should be deposited in.

Enter the contact person's name, title, telephone number, and email address (if applicable) who is responsible for answering questions about the information submitted on the EFT form.

By signing 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 Provider or Supplier. The Provider or Supplier has sole control of the account to which EFT deposits are made in accordance with all applicable Medicare regulations and instructions. All arrangements between the financial institution and the said Provider or Supplier are in accordance with all applicable Medicare regulations and instructions with the effective date of the EFT authorization. You must notify the Medicare contractor regarding any changes to the account in sufficient time for the contractor and the depository to act on the changes.

The EFT authorization form must be signed and dated by the same Authorized Representative or a Delegated Official named on the CMS-855 Medicare enrollment application which the Medicare contractor has on file. 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 copied or stamped signatures can be accepted) to the Medicare contractor that services your geographical area. The date the form is signed also needs to be included in order for the signature to be accepted.

An EFT authorization form must be submitted for each Medicare contractor to whom you submit claims for Medicare payment.

1. Voided check, must include:
   1. The Name on the account. This must be the full Legal Name/ Legal Business Name.
   2. The routing number must be visible on the check.
   3. The account number must be visible on the check.
   4. Starter checks are not acceptable. Please provide a bank generated check or request a bank letter.
   5. Sole proprietors and Sole owned corporations/ Incorporated Individuals can only have their name as owner of the account. Spouses, partners, or other individuals cannot share ownership for a bank account used with Medicare.

   

2. Bank Letter, must include:
   1. Must be submitted with the bank's letterhead.
   2. Routing Number on the account including leading zeros
   3. Account Number on the account including leading zeros
   4. Type of Account- checking or savings
   5. If the account is for a sole proprietor or sole owned corporation, then the bank must verify that the provider is the only owner of that account.
   6. Full Legal Business Name must be used as the account name, and must be indicated on the letter.
   7. The bank officer's name and signature is required.