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EDI forms

EDI feedback
Modified: 2/23/2024
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: 4/12/2024
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: 4/12/2024
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: 6/24/2024
This form is for third-party agents such as clearinghouses and billing services to enroll for electronic transactions. [CR 8756]
Modified: 6/24/2024
This interactive “Electronic Data Interchange (EDI) enrollment form” is intended for provider use only.
Modified: 9/5/2024
This form is to change the address or contact information for an existing EDI Submitter ID.
Modified: 9/5/2024
This form is to enroll multiple group or solo providers with the EDI enrollment or SPOT enrollment process.
Modified: 11/26/2024
EDI enrollment forms may be submitted via email or fax.
Modified: 8/27/2024
Software vendors, billing services, and clearinghouses should complete the Electronic Data Interchange (EDI) Third Party Enrollment form to initially enroll for electronic billing with First Coast or make changes to their current EDI setup.
Modified: 8/27/2024
These instructions will assist you in completing the EDI enrollment form (8292).
Modified: 2/22/2024
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 R1-22.
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.