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EDI forms

Modified: 10/25/2019
This new interactive form is for use by third-party agents such as clearinghouses, billing services, and Network Service Vendors only. All requests for new submitter numbers require provider to complete and sign an EDI enrollment form. This form was updated in October, 2019. Any version of the previous form will not be accepted as of December 1, 2019. [CR 8756]
Modified: 10/25/2019
This new interactive “Electronic Data Interchange (EDI) enrollment form” has been revised as of October 2019. This form is intended for provider use only and replaces previous EDI enrollment forms. Please see How to complete the EDI enrollment form for completion assistance. Previous forms will not be accepted as of December 1, 2019.
Modified: 10/25/2019
This EDI Update Request Form is used update a trading partners information such as demographics and contact information. The Legal Business name and the Tax ID# must match what is currently on file for the Trading Partner.
Modified: 10/25/2019
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.
Modified: 10/25/2019
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.
Modified: 10/24/2019
This presentation provides step by step instructions on how to complete Electronic Data Interchange (EDI) Third Party Enrollment form. The Third Party EDI Enrollment form is intended for third party organizations such as billing services and clearinghouses only and replaces previous Network Service Vendor Agreement form.
Modified: 10/24/2019
This presentation provides step by step instructions on how to complete Electronic Data Interchange (EDI) enrollment form. The EDI Enrollment form is intended for provider use only and replaces previous EDI enrollment forms.
Modified: 10/3/2019
Only an authorized or delegated official as defined by the Centers for Medicare & Medicaid Services (CMS) can sign the EDI Enrollment form, DDE access request form, agreements, and other EDI forms.
Modified: 9/12/2019
Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim. This is NOT an EDI enrollment form. [CR 10397]
Modified: 9/12/2019
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.