skip to content
Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.
To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:
Select which best describes you:
Select your location:
Select your line of business:
This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. Information for Medicare beneficiaries is only available on the medicare.gov website.
En Español
Text Size:
Send a link to this page
[Multiple email adresses must be separated by a semicolon.]

Forms

Quick clicks
List item Having trouble viewing 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.
Claims
List itemMedicare Part A PWK fax/mail coversheet pdf -- Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim.
Direct Data Entry (DDE)
EDI
List itemEDI forms -- find the EDI forms you need to begin electronic submissions of claims as well as an electronic data request form to apply for or revise existing information pertaining to the Electronic Remittance Advice (ERA) and/or Electronic Claim Status (ECS) transactions.
Overpayment
List item Extended repayment schedule form pdf -- this document is required to consider an extended repayment schedule request.
List item Overpayment reporting pdf -- use this interactive form when reporting overpayments.
List itemRequest for immediate offset pdf -- use this interactive form when requesting immediate offset of overpayments.
PARD
List itemPARD forms -- find the forms you need to submit interim rate and periodic interim payment (PIP) requests as well as statistical and reimbursement report fax sheets.
Provider enrollment
List itemProvider Enrollment forms -- Learn which forms meet your enrollment needs and how to submit them. Find links to required enrollment applications (CMS-855), Participating physician or supplier agreement (CMS-460), and Electronic file transfer (EFT) applications (CMS-588).
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.