Wednesday, May 8, 2013
Medicare EFT form submission instruciton
From Medicare website you can download the form. For Florida state, I have given the link.
INSTRUCTIONS FOR COMPLETING THE EFT AUTHORIZATION AGREEMENT
All EFT requests are subject to a 15-day pre-certification period in which all accounts are verified by the qualifying financial institution before any Medicare direct deposits are made.
PART I: REASON FOR SUBMISSION
Indicate your reason for completing this form by checking the appropriate box: New EFT authorization or change to your
account information. 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 authorizing the contractor to make payment due the provider of service to the account maintained by the home office of the chain organization. The letter must be signed by an authorized official of the provider of service and an authorized official of the chain home office.
PART II: PROVIDER OR SUPPLIER INFORMATION
Enter the provider’s/supplier’s legal business name or the name of the physician or individual practitioner, as reported to the Internal Revenue Service (IRS). The account to which EFT payments made must exclusively bear the name of the physician or individual practitioner, or the legal business name of the person or entity enrolled with Medicare.
Enter the chain organization’s name or the home office legal business name if different from the chain organization name.
Enter the account holder’s street address.
Enter the account holder’s city, state, and zip code.
Enter the tax identification number as reported to the IRS. If the business is a corporation, provide the Federal employer identification number, otherwise provide your Social Security Number.
If issued, enter the Medicare identification number assigned by a Medicare fee-for-service contractor. If you are not enrolled in Medicare, leave this field blank.
Enter the 10 digit NPI number. The NPI is required to process this form.
PART III: FINANCIAL INSTITUTION INFORMATION
Enter your Financial Institution’s name (this is the name of the bank or qualifying depository that will receive the funds). Note: The account name to which EFT payments will be paid is to the name submitted on Part II of this form.
Enter the city or town where your financial institution is located. Enter the state where your financial institution is located.
: Enter the bank or financial institutional telephone number and contact person’s name.
: Enter the bank or financial institutional nine-digit routing number, including applicable leading zeros.
: Enter the depositor’s account number, including applicable leading zeros. Select the account type.
If you do not submit this information, your EFT authorization agreement will be returned without further processing.
PART : CONTACT PERSON
: Enter the name and title of a contact person who can answer questions about the information submitted on this
Enter the contact person’s telephone number. Enter the contact person’s e-mail address.
PART v: AUTHORIZATION
By your signature on this form you are certifying that the account is drawn in the Name of the Physician or Individual Practitioner, or the Legal Business Name of the Provider or Supplier. The Provider or Supplier has sole control of the account to which EFT deposits are made in accordance with all applicable Medicare regulations and instructions. All arrangements between the Financial Institution and the said Provider or Supplier are in accordance with all applicable Medicare regulations and instructions with the effective date of the EFT authorization. you must notify CMS regarding any changes in the account in sufficient time to allow the contractor and the Financial Institution to act on the changes.
The EFT authorization form must be signed and dated by the same Authorized Representative or a Delegated Official named on the CMS-855 Medicare enrollment application which the Medicare contractor has on file. Include a telephone number where the Authorized Representative or Delegated Official can be contacted.
Mail this form with the original signature in black or blue ink (no facsimile signatures can be accepted) to the Medicare
contractor that services your geographical area. An EFT authorization form must be submitted for each Medicare contractor to whom you submit claims for Medicare payment. To locate the mailing address for your fee-for-service contractor, go to:
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