Electronic Funds Transfer Authorization Agreement

Forms and Documents

Document Name	Status
Form CMS-588 Electronic Funds Transfer Authorization Agreement Form and Instruction	Modified
(0938-0626).CMS-588 public comment responses from 30-day FRN.doc Supplementary Document	2010-04-13
CMS-588 - Revisions Crosswalk - 01042010.doc Supplementary Document	2010-01-22
CMS-588.Supporting Statement.doc Supporting Statement A	2010-01-22

IC Document Collections

IC ID	Document Title	Status
43660	Electronic Funds Transfer Authorization Agreement Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0626	ICR Reference No: 201002-0938-002
Status: Historical Active	Previous ICR Reference No: 200607-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Electronic Funds Transfer Authorization Agreement
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/20/2010
	Date Received in OIRA: 02/04/2010
Terms of Clearance: OMB notes that CMS made changes to the instrument after submission to address public comments received during the 30-day comment period.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2013	36 Months From Approved
Responses	100,000	0	0
Time Burden (Hours)	100,000	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The legal authority to collect this information is found in Sections 1815(a) and 1835(a) of the Social Security Act. The general reporting requirements originated in FR Doc 92-22508, published on October 21, 1992. This document established that providers/suppliers who qualify for EFT and wish to receive payments electronically request such in writing from their fiscal intermediary or carrier. Under 31 U.S.C. 3332(f)(1), all Federal payments, including Medicare payments to providers and suppliers, shall be made by electronic funds transfer.

---

Authorizing Statute(s): US Code: 31 USC 3332(f)(1) Name of Law: Required Direct Deposit
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 47945	09/18/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 2548	01/15/2010
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Electronic Funds Transfer Authorization Agreement	CMS-588	ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	100,000	0	0	0	0	100,000
Annual Time Burden (Hours)	100,000	0	0	0	0	100,000
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/04/2010

---