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Printed Date: 9/22/2015
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Application Fee Receipt
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No - If no change in TIN
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No - If no change in TIN
If revalidating and supplier is not already enrolled to receive payments through electronic funds transfer, the supplier should submit the Authorization Agreement for Electronic Funds Transfer (CMS 588). Suppliers must ensure the form has the original signature of the authorized or delegated official. Also, suppliers should submit a separate form for each Medicare contractor where it submits claims. In addition, suppliers are required to attach either a voided check, deposit slip or letter on bank letterhead verifying the account information. Either one of these attachments must be included with each form submitted.
Also note, if a supplier is deleting an individual from the supplier file, no additional documentation is required to be submitted. For example, if a supplier is removing a board member, the NSC will not require additional documentation such as board minutes to remove the individual. As long as the appropriate section in PECOS is completed correctly to delete the individual and the certification statement is signed and submitted properly, the individual will be removed from the file.
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Last Updated: 03/01/2021
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