Last Modified: 5/12/2020
Location: FL, PR, USVI
Business: Part B
Q: What information should be in Section 6 of the CMS-855R form?
A. The following information is required:
Section 6A is signed and dated by the person reassigning their benefits. Section 6B is signed and dated by the group’s authorized official or delegated official. If either signature is missing, First Coast Service Options Inc. (First Coast) will request this information as part of the development process.
If the individual terminates a reassignment, the individual signs and dates section 6A.
If the organization terminates a reassignment, the group’s authorized official or delegated official signs and dates Section 6B.
For terminations, both signatures are not required. However, if no signatures are present, First Coast will request this information as part of the development process.
The authorized or delegated official who signs section 6B must be currently on file with First Coast. All signatures must be original, preferably in blue ink. Faxed, stamped, or photocopied signatures cannot be accepted.
If the application is not signed and dated appropriately, First Coast will send a development letter requesting this information. The corrected information will need to be returned within 30 days or the applications will be rejected.
Please use your browser's back button
to return to the referring page.
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.