Electronic Funds Transfer (EFT) Authorization Agreement {CMS-588}

CMS-2728 - ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT. This form is used for enrolling providers or suppliers in the Medicare program to receive payments electronically via Electronic Funds Transfer (EFT). It requires providers to indicate whether they are submitting a new EFT enrollment or updating existing information. The form collects account holder information, including legal business name, address, tax identification number (TIN), National Provider Identifier (NPI), and Medicare identification number. Providers must also provide financial institution details such as name, address, contact person, routing transit number, and account number. A contact person for inquiries is required. The form includes an authorization section where providers certify control of the account and compliance with Medicare regulations. It must be signed and dated by an authorized representative or a delegated official named on the CMS-855 Medicare enrollment application. All EFT requests are subject to a pre-certification period in which all accounts are verified by the qualifying financial institution before any Medicare direct deposits are made. www.FormsWorkflow.com