Form 2025

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The document is an Electronic Funds Transfer (EFT) Authorization Agreement from the Centers for Medicare & Medicaid Services (CMS). It outlines the process for providers to enroll in, change, or cancel their EFT enrollment for receiving Medicare payments. The form requires detailed information about the provider, financial institution, and authorization details. It emphasizes compliance with Medicare regulations and includes instructions for completing the form.

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Click ‘Get Form’ to open the EFT Authorization Agreement in our editor.
In Part I, select your reason for submission by checking the appropriate box: New EFT Enrollment, Change to Current EFT Enrollment, or Cancel EFT Enrollment. If applicable, attach a letter authorizing payment to the Chain Home Office.
Proceed to Part II and fill in the Account Holder Information. Enter the legal business name, practice location address, Tax Identification Number (TIN), and National Provider Identifier (NPI) as required.
In Part III, provide details about your Financial Institution including its name, address, routing number, and account number. Ensure you specify whether it’s a Checking or Savings account.
Complete Part IV by entering the Contact Person's information who can answer questions regarding this form.
Finally, in Part V, authorize the agreement by signing and dating the form. Make sure to include your contact details for any follow-up.

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Versions	Form popularity	Fillable & printable
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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From Middle English forme (shape, figure, manner, bench, frame, seat, condition, agreement, etc.), borrowed from Old French forme, from Latin fōrma (shape, figure, image, outline, plan, mold, frame, case, etc., manner, sort, kind, etc.).

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