Submit Enrollment Application

Electronic Funds Transfer Agreement

Download and complete the CMS-588 EFT Authorization Agreement.

Physicians and nonphysician practitioners who are reassigning all of their payments to another entity are not required to submit the CMS-588.

Required Documents

  • A voided check or confirmation of account information on bank letterhead
    • Document must contain:              
      • provider/legal business name on the account
      • electronic routing transit number
      • account number
      • account type (checking or saving)
      • bank symbol or logo
      • name on the EFT form and the name on the checking or saving account must match exactly
      • bank officer’s first and last name and signature required for confirmation that is on letterhead document
  • Lending relationship letter (bank agreement to waive Medicare offsets) if applicable

 Not Acceptable

  • Deposit slip or direct deposit authorization forms
  • Money market accounts
  • The bank account cannot be a joint account or “doing business as” name

Related Content

Reviewed 6/13/2024

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS

J6 Mailing Address:

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Interactive Voice Response:

877-908-9499

Contact Enrollment:

877-908-8476

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. CT

Form(s) you'll need:

Enrollment Forms

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS
Pay Application Fee

JK Mailing Address:

National Government Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149

Interactive Voice Response:

877-869-6504

Contact Enrollment:

888-379-3807

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. ET

Form(s) you'll need:

Enrollment Forms

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS

J6 Mailing Address:

National Government Services, Inc.
P.O. Box 6474
Indianapolis, IN 46206-6474

Contact Enrollment:

855-834-5596

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. CT
9:00 a.m.–5:00 p.m. ET

*Closed for training on the 2nd and 4th Friday of the month
12:00 p.m.-4:00 p.m. ET
11:00 a.m.-3:00 p.m. CT

Form(s) you'll need:

CMS-855A - Medicare Enrollment Application form for Institutional Providers
CMS-588 - Electronic Funds Transfer (EFT) Authorization Agreement form

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS
Pay Application Fee

JK Mailing Address:

National Government Services, Inc.
P.O. Box 7149
Indianapolis, IN 46206-7149

Contact Enrollment:

855-593-8047

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. ET

*Closed for training on the 2nd and 4th Friday of the month
12:00 p.m.-4:00 p.m. ET

Form(s) you'll need:

CMS-855A - Medicare Enrollment Application form for Institutional Providers
CMS-588 - Electronic Funds Transfer (EFT) Authorization Agreement form