Supporting Documentation Required for Enrollment Revalidations

Submit all required documentation based on your revalidation scenario:

• Written confirmation from the IRS confirming your legal business name and EIN (e.g., IRS CP-575)
  • The legal business name as it appears on Social Security records and/or IRS documents must match the NPPES Registry exactly, including any suffix such as PC, PA, LLC, etc.
• Copy of national certification and diploma for nonphysician practitioners that require it
• Copy of DEA certificate for providers when applicable.
• Copy of the application fee receipt if you are required to pay the application fee
• Complete Form CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement CMS-588
  • This form CMS-588 is not required if:
    • the current EFT agreement was submitted on the 05/10, 09/13, 01/17 or 12/23 version of the CMS-588 form,
    • the EFT information was submitted via PECOS, under the PECOS topic “Electronic Funds Transfer,”
    • an individual provider reassigns all benefits.

For revalidation submitters using PECOS, the Financial/Electronic Funds Transfer Topic replaces the need for a CMS-588 paper agreement. If you are making changes to EFT information in PECOS, you should upload (PDF or TIFF) a voided check or confirmation on bank letterhead listing name on the account, electronic routing transit number, account number, account type and bank officer’s full name and signature.

Related Content

• CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement CMS-588
• Electronic Funds Transfer Form and Instructions
• NPPES NPI Registry

Revised 7/29/2024