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Digital sign money transfer agreement template

welcome to the training for completing the CMS form 588 electronic funds transfer EFT to change the EFT information EFT is required for all providers newly enrolled in Medicare or making changes to the enrollment information not all changes require a change to the electronic funds transfer agreements if you have one in place this training will walk you through the process of completing the form 588 and help you to avoid delays in the provider enrollment process WPS GHA designed this program with the most current information available all current rules and regulations will prevail the EFT agreement CMS 588 form is required in some circumstances complete the form for new enrollment updating banking information when a change of ownership occurs and adding new or changed practice locations remember this form is not required for providers reassigning all of his or her benefits or during the revalidation process the first thing we recommend is gathering the forms as previously mentioned you will need to CMS 588 form the form is available on the CMS website in the form section the path to locate the form section is listed on the slide the form will look like this the form has instructions on page 3 as we move through the pages during the presentation each page number represents the CMS form on the CMS website let's begin to complete the form start on page 1 part 1 check the box for the reason you are completing the form if the EFT payment is made to your home office then check the box and ensure a letter from the home office is attached the letter must give you authorization to change the payment to the home office if either a change of ownership and or practice location is being completed then make sure the form accompanies the correct 8:55 provider enrollment form next move to part 2 this section is completed with the account holder information this information must match what the bank has on file list your providers legal business name if the chain of home office will receive payments list its legal business name remember these sections must match the name on the bank account move to the account holders address complete the street address city state and zip code this section must match the bank account information the address must match the application in 4a or be on file with Medicare enrollment as the form states this is a street address and Pio boxes are not acceptable if the chain home office will receive payment and was selected in section one complete this section with its address list the tax identification number from the IRS for an individual this will be his or her social security number for everything else this will be the ein once the number is listed check the appropriate sections to identify it list the Medicare identification number also known as the provider transaction access number or P tan if that has been issued if the provider has been rolling for the first time then leave this field blank enter the national provider identifier or the NPI of the organization this is a type 2 NPI if you are enrolling a group indicate a type 1 NPI if you are enrolling an individual moved down to part 3 for bank information enter the bank's name next complete the street address city state and zip code of the bank note this cannot be a P o box next enter the bank's phone number complete the contact person for the bank who is able to verify the bank's setup information if you do not have a specific person leave this field blank enter the bank's routing number the organization or providers account number and indicate the type of account the banking information in section brief must be accompanied by documented account information WPS GHA will accept a voided check printed with the following information full account number ACH routing number bank name and full account name please note it cannot be a starter check a bank letter will also be accepted if it includes the following on the bank letterhead the full account number the ACH routing number the type of account full name on the accounts and signed by the bank of the show note the bank letter cannot be dated more than one year from the EFT form date incomplete information will cause the application to be developed on or rejected on page to complete the contact person the person listed will need to be able to answer any questions about the EFT agreement complete the contact persons first and last name enter the person's title within your organization enter a phone number with area code and email address where the person can be reached remember the contact person may be contacted by phone or email to verify information on this application move to the signature field complete the information for the person who is the authorized or delegated official on the CMS 855 form or on file with Medicare enter the person's name phone number title and email address if you not have a person listed on your provider enrollment file complete the appropriate sections of the 855 form once the person's information is listed have the authorized or delegated official sign the form in blue ink and enter the date remember all signature requirements must be met the requirements indicate that signatures must be dated within a hundred and twenty days prior to the date of the receipt must be dated to be valid and must be signed in blue ink remember to include either a voided check or a bank letter also verify that the legal business name is listed on the account the correct address is listed on the application and the application is signed we hope that you have a better understanding of completing the 508 electronic funds transfer EFT agreement remember medicare requires all providers to receive payment via EFT there are many different tutorials to help you through the specific enrollment situation on both the CMS website and WPS GHA portal please take time to review the ones applicable to the actions you are taking have a great day