DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0626 ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT PART I: REASON FOR SUBMISSION Reason for Submission: New EFT Enrollment Change to Current EFT Enrollment (e.g. account or bank changes) Check here if EFT payment is being made to the Home Office of Chain (Attach letter Authorizing EFT payment to Chain Home Office) Cancel EFT Enrollment Change of Ownership, and/or Change of Practice Location? Since your last EFT authorization agreement submission, have you had a: If you checked either a change of ownership or change of practice location above, you must submit a change of information (using the Medicare enrollment application) to the Medicare contractor that services your geographical area(s) prior to or accompanying this EFT authorization agreement submission. PART II: ACCOUNT HOLDER INFORMATION Provider/Supplier/Indirect Payment Procedure (IPP) Biller Legal Business Name Chain Organization Name or Home Office Legal Business Name (if different from Chain Organization Name) Account Holder's Practice Location Street Address Account Holder's Practice Location City Tax Identification Number (designate SSN or EIN) Account Holder's Practice Location State Account Holder's Practice Location Zip Code Medicare Identification Number (if issued) Health Plan Identifier (HPID) or Other Entity Identifier (OEID) (IPP Entities Only) National Provider Identifier (NPI) National Provider Identifier (NPI) National Provider Identifier (NPI) PART III: FINANCIAL INSTITUTION INFORMATION Financial Institution's Name Financial Institution's Street Address Financial Institution's City/Town Financial Institution's Telephone Number Financial Institution Routing Number Financial Institution's State/Province Financial Institution's Contact Person Financial Institution's Zip/Postal Code Provider's/Supplier's/IPP Entity's Account Number with Financial Institution Type of Account (check one) Checking Account Savings Account Please include a confirmation of account information on bank letterhead or a voided check. When submitting the documentation, it should contain the name on the account, electronic routing transit number, account number and type. If submitting bank letterhead, the bank officer's name and signature is also required. This information will be used to verify your account number. PLEASE NOTE: In accordance with section 1104 of the Affordable Care Act, enrollment of electronic fund transfer (EFT) is for electronic fund transfer authorization only. EFT enrollment does not constitute enrollment as a provider or supplier in the Medicare program. Form CMS-588 (09/13) American LegalNet, Inc. www.FormsWorkFlow.com 1 PART IV: CONTACT PERSON Contact Person's Name Contact Person's Telephone Number Contact Person's Title Contact Person's E-mail Address PART V: AUTHORIZATION I hereby authorize the Centers for Medicare & Medicaid Services (CMS) to initiate credit entries, and in accordance with 31 CFR part 210.6(f) initiate adjustments for any duplicate or erroneous entries made in error to the account indicated above. I hereby authorize the financial institution/bank named above to credit and/or debit the same to such account. CMS may assign its rights and obligations under this agreement to CMS' designated fee-for-service contractor. CMS may change its designated contractor at CMS' discretion. If payment is being made to an account controlled by a Chain Home Office, the Provider of Services hereby acknowledges that payment to the Chain Office under these circumstances is still considered payment to the Provider, and the Provider authorizes the forwarding of Medicare payments to the Chain Home Office. If the account is drawn in the Physician's or Individual Practitioner's Name, or the Legal Business Name of the Provider/Supplier or IPP entity, the said Provider/Supplier or IPP entity certifies that he/she has sole control of the account referenced above, and certifies that all arrangements between the Financial Institution and the said Provider/Supplier or IPP entity are in accordance with all applicable Medicare regulations and instructions. This authorization agreement is effective as of the signature date below and is to remain in full force and effect until CMS has received written notification from me of its termination in such time and such manner as to afford CMS and the Financial Institution a reasonable opportunity to act on it. CMS will continue to send the direct deposit to the Financial Institution indicated above until notified by me that I wish to change the Financial Institution receiving the direct deposit. If my Financial Institution information changes, I agree to submit to CMS an updated EFT Authorization Agreement. SIGNATURE LINE Authorized/Delegated Official Name (Print) Authorized/Delegated Official Title Authorized/Delegated Official Telephone Number Authorized/Delegated Official E-mail Address Date Authorized/Delegated Official Signature (Note: Must be original signature in black or blue ink.) 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. You should be aware that P.L. 100-503, the Computer Matching and Privacy Protection Act of 1988, permits the government, under certain circumstances, to verify the information you provide by way of computer matches. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0626. The time required