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Last Modified: 10/3/2019 Location: FL, PR, USVI Business: Part A, Part B

Authorized officials signatures on EDI enrollment and DDE request for access forms

First Coast Service Options Inc. (First Coast) would like to remind providers that only an authorized official or a delegated official, as listed on the CMS 855, can sign the Electronic Data Interchange (EDI) enrollment form, Direct Data Entry (DDE) Access Request form and other EDI forms.
The CMS defines an authorized official as “an appointed official, such as a chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner, to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s status in the Medicare program, and commit the organization to fully abide by the statutes, regulations, and instructions of the Medicare program.”
As of March 1, 2016, any DDE Request for Access form or any other EDI forms not signed by an authorized or delegated official will be rejected. A new form will be required.
The EDI forms certification statement states that “by signing the form the signee certifies that he or she have been appointed an authorized individual to whom the provider has granted the legal authority to enroll it in the Medicare Program, to make changes and/or updates to the provider's status in the Medicare Program (e.g., new practice locations, change of address, etc.), and to commit the provider to abide by the laws, regulations, and the program instructions of Medicare.”
The new EDI forms are designed to be completed online, and can be signed electronically. There are three methods for submitting your EDI forms:
By mail to: First Coast Medicare EDI, P.O. Box 44071, Jacksonville, FL 32231-4071
By fax to: 904-361-0470
By email to:
As of November 5, 2018, any EDI form submitted on an outdated form will be rejected. The current DDE Request for Access form was updated on February 27, 2019, and the EDI Enrollment form was revised September 7, 2018. All forms received after 2 p.m. ET will have the date of receipt of the next business day. Please allow 10 business days before contacting Medicare EDI for a status of an application.
For questions contact First Coast Medicare EDI Support team at 888-670-0940.
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.