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The document is an Electronic Funds Transfer (EFT) Authorization Agreement form from the Centers for Medicare & Medicaid Services (CMS). It outlines the process for providers to enroll in EFT for receiving Medicare payments, including sections for submission reasons, account holder information, financial institution details, contact person information, and authorization. The form requires specific data about the provider and their bank account, and emphasizes compliance with Medicare regulations. It also includes instructions for completing the form and notes on privacy and processing.

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2020	4.8 Satisfied (144 Votes)
2017	4 Satisfied (43 Votes)
2013	4.4 Satisfied (328 Votes)
2010	4.2 Satisfied (58 Votes)
2006	4.4 Satisfied (59 Votes)

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