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Electronic Funds Transfer Authorization Form
Enter only one provider number per application form. Provider Groups that receive payments under the Group number need only complete a single enrollment form
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Electronic Funds Transfer Enrollment Form
Electronic Funds Transfer Enrollment Form. Please review the terms and conditions before completing this form. Please check one: [ ] New Enrollment [ ] Change.
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Electronic Funds Transfer Authorization Agreement CMS-588
PART I: REASON FOR SUBMISSION. Indicate your reason for completing this form by checking the appropriate box: New EFT enrollment or change to your EFT.
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