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First Coast Service Options Inc.
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Forms

Appeals
List itemRequest for telephone clerical reopening form pdf -- use this form to request a clerical reopening over the telephone. All related information must be completed on the form for the request to be honored.
List item3rd level: Hearing by and administrative law judge – ALJ form CMS 20034external pdf -- if at least $130 remains in controversy, an administrative law judge (ALJ) hearing may be requested.
List item4th level: Medicare Appeals Council form DAB-101external pdf -- Departmental Appeals Board form for filing an appeal with the Medicare Appeals Council if dissatisfied with the ALJ’s decision.
List itemCMS 1696: Appointment of representativeexternal link -- used by beneficiaries to authorize an individual to act as a representative in connection with a Medicare appeal.
EDI
List itemEDI forms -- find the EDI forms you need to begin electronic submissions of claims as well as an electronic data request form to apply for or revise existing information pertaining to the Electronic Remittance Advice (ERA) and/or Electronic Claim Status (ECS) transactions.
Immunization roster billing
List itemInfluenza virus vaccine roster pdf -- here is a roster to use to capture patient information when creating an influenza virus vaccine roster.
List itemInfluenza virus vaccine - sample CMS 1500 pdf -- use this example to learn how to complete the CMS-1500 form when roster billing claims for influenza.
List itemPneumococcal pneumonia virus vaccine roster pdf -- here is a roster to use to capture patient information when creating a pneumococcal pneumonia virus vaccine roster.
List itemPneumococcal pneumonia virus vaccine - sample CMS-1500 pdf -- use this example of how to complete the CMS-1500 form when roster billing claims for pneumococcal pneumonia virus vaccine.
Medicare Secondary Payer (MSP)
Overpayment
List item Extended repayment schedule for corporation or group form pdf -- this document is required to consider an extended repayment schedule request for a corporation or group.
List item Extended repayment schedule for sole proprietor form pdf -- this document is required for sole proprietors who wish to request an extended repayment schedule.
List item Request for immediate offset form pdf -- use this interactive form when requesting immediate offset of overpayments.
Provider enrollment
List itemInternet-based PECOSexternal link -- begin the Medicare provider enrollment process here.
List itemCMS-460external pdf -- Medicare Participating Physician or Supplier Agreement.
List itemCMS-855 forms -- links to Medicare provider paper enrollment 855 forms.
List itemRevalidation FAQs -- learn how to recognize and respond to a revalidation request, when you should revalidate, and the answers to other frequently-asked questions about this important initiative.
List itemCMS-588 - Electronic funds transfer (EFT) information -- this page provides details about the EFT form; including where to mail the completed form.
List itemCMS-588 - Electronic funds transfer (EFT)external pdf -- use this form to enroll or revise direct deposit authorization that directly allows the transfer of Medicare payments.
Other
List itemCMS’ Beneficiary Notices Initiative (BNI) -- links to commonly-used beneficiary notices such as ABNs, FFS and HINNs.
List itemCMS-1500 (08/05) paper claim form -- find information on where to obtain and how to complete the CMS 1500 claim form.
List itemCMS.gov forms pageexternal link -- access and information for CMS’ forms.
List itemCMS-838 – Medicare Credit Balance Report form external pdf-- this report is required of the Social Security Act. Failure to submit this report may result in a suspension of payments under the Medicare program and may affect your eligibility to participate in the Medicare program.
List itemOrder form -- 2013 Part B materials pdf -- items available for purchase are the 2013 Fee Schedule and an annual subscription to the Medicare B Connection.
Part B
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.