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.
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]
Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim. This is NOT an EDI enrollment form. [CR 10397]
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.
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.
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.
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.
