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Completing the Medicare CMS-588 enrollment application

EFT authorization agreement

The Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) application is used to have Medicare reimbursements deposited directly into a provider's/ supplier's bank account. 

CMS requires all providers enrolling in Medicare to receive Medicare payments via EFT. The EFT form must be submitted for new enrollments, changes to banking information, or any existing provider not already enrolled in EFT. 

The chart below is designed to provide additional instructions for completing the enrollment application. Be sure to follow all guidelines listed on the application.

Note: Once the application is completed, mail the application to First Coast. The CMS-588 EFT application cannot be accepted via the Provider Enrollment Gateway tool.

Section of form Best Practices
Part I: Reason for submission

If new submission, check New EFT Enrollment, then check box for individual or group:

  • Individuals who own a sole owner group must select group and provide all group information

If a change to current EFT enrollment (e.g., account or bank changes) check that box

If you are authorizing EFT payments to the home office of a chain organization of which you are a member, you must attach a letter:

  • Letter must be signed by an authorized official of the provider of service and an authorized official of the chain home office
Part II: Account holder information

Organizations:

  • Legal business name on application, enrollment file, and voided check/bank letterhead must match what is reported to the IRS

Individuals:

  • First and last name on application, enrollment file, and voided check/bank letterhead must match what is reported to the Social Security Administration

Bank accounts cannot be jointly held

Chain organization name or home office LBN and chain home office number (if applicable)

Account holder’s street address, city, state, and ZIP code

  • Do not use P.O. Boxes

Tax identification number (TIN) – check box to designate if TIN is an SSN (individual) or EIN (organization)

NPI and Medicare identification number (PTAN or CCN), if issued
Part III: Financial institution information

Furnish the following financial institution information:

  • Name
  • Street address, city, state, ZIP code
    • Do not use P.O. Boxes
  • Telephone number 
  • Contact person
  • Routing transit number
  • Provider’s account number (include all zeroes) 
  • Type of account (checking or savings)

Account and routing number must match the supporting documentation (voided check or bank letter) exactly
Part IV: Contact person

Furnish the following information for the person who can be contacted for questions about the EFT:

  • Name 
  • Title
  • Telephone number
  • Email address
Part V: Authorization

The EFT authorization form must be signed and dated by the authorized or delegated official named on the application or the existing Medicare enrollment record.

Read the certification statement

Enter the following for the authorized or delegated official: 

  • Name
  • Telephone number 
  • Email address
  • Signature
  • Date signed

Signatures must be handwritten or use an eligible digital signature (e.g., DocuSign, AdobeSign), as well as dated. Stamped signatures will not be accepted.
Additional guidance and required documentation

Depending on the reason for submission, we may need phone verification before approving the application.

A group does not need to submit an EFT for each of its members. Only the group submits the form, files claims, and receives reimbursement.

A voided check or bank letterhead is required in the provider's/supplier's legal business name only.

Submit one of the following supporting documents with the EFT form:

  • Voided check (starter checks/deposit slips are not acceptable)
  • Bank letter on financial institution letterhead which includes:
    • Name on account/account type
    • Account number/routing number
    • Bank officer’s name and signature