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Forms

Quick clicks
List item Prepay Claims Additional Documentation Response (ADR) fax coversheet -- Part A
Appeals
List item3rd level: Forms pertaining to a level 3 appeal -- a request for a hearing by an Administrative Law Judgeexternal link
List item4th level: Medicare Appeals Council form DAB-101external pdf
List itemCMS 1696: Appointment of representativeexternal link
Claims
List itemMedicare Part A PWK fax/mail/esMD coversheet pdf -- Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim - required for forms received on and after April 1, 2018.
Direct Data Entry (DDE)
List itemGain access to perform DDE functions pdf
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).
Other
List itemPrepay Claims Additional Documentation Response (ADR) fax coversheet -- Part Apdf
List itemPost-Payment Probe Review Documentation Response (ADR) fax coversheet -- Part Apdf
List itemCMS’ Beneficiary Notices Initiative (BNI) -- links to commonly used beneficiary notices such as ABNs, FFS and HINNs.
List itemCMS.gov forms pageexternal link
List itemPurchase an annual publication subscription to the Medicare A Connection pdf
List itemHow to request Form 1099
List itemRequest for assistance to resolve overlapping claims
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.