DMEPOS suppliers are required to submit the EFT agreement with the application form when initially enrolling or submitting an application for a new location.
When completing the form, suppliers should ensure the form has the original signature of the authorized or delegated official. Further, suppliers must include with each form submitted a voided check, preprinted deposit slip or confirmation of account information on bank letterhead for verification of the account number.
The NSC will then send the agreement to the appropriate DME MAC for processing.
The CMS 588 (PDF, 112 KB) form may be downloaded from the CMS website.