This new interactive “Electronic Data Interchange (EDI) enrollment form” has been revised. This form is intended for provider use only and replaces previous EDI enrollment forms. Previous forms will not be accepted as of August 16, 2022.
This new interactive "Third Party HTTPS CAQH CORE EDI Enrollment Form” is intended for third party trading partners such as billing services or clearinghouses. Please see the HTTPS CAQH CORE Connection Guide for connectivity requirements. This form was updated in October 2019. Any previous versions of this form will not be accepted as of December 1, 2019.
This new interactive "Provider Third Party HTTPS CAQH CORE EDI Enrollment Form” is intended for trading partner provider use only. Please see the HTTPS CAQH CORE Connection Guide for connectivity requirements.
Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim. This is NOT an EDI enrollment form. [CR 10397]
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.