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EDI forms

EDI Support

General/password help:
888-670-0940 option-1
888-670-0940 option-2
888-670-0940 option-3
888-670-0940 option-4

Having trouble with forms?

Certain browsers have issues with interactive PDF forms. It is recommended to download and save the PDF by right clicking on the link to the PDF. Once the document is saved, first open your PDF reader and then open the file from within your reader. Additional information may be found on Adobe Acrobat's help documentexternal.
Modified: 11/2/2018
These completion instructions are for the current electronic data interchange (EDI) enrollment form. This form is intended for provider use only and replaces previous EDI enrollment forms.
Modified: 10/10/2018
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: 9/30/2018
This 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. [CR 8756]
Modified: 9/19/2018
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: 9/2/2018
This interactive “Electronic Data Interchange (EDI) enrollment form” has been revised as of November 20, 2018. 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.
Modified: 6/13/2018
This interactive "HTTPS CAQH CORE EDI Enrollment Form” is effective as of April1, 2017. This form is intended for trading partner use only. Please see the HTTPS CAQH CORE Connection Guide for connectivity requirements.
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.
Part A