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Forms

Electronic submission
Avoid the wait, submit electronically
Claims
List itemMedicare Part B 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.
List itemAvoid processing issues: Submitting the correct form is important -- Use the correct form today to avoid processing issues.
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.
Immunization roster billing
List itemCOVID-19 vaccines or monoclonal antibody infusion: Roster sheet pdf -- This roster may be used to capture patient information when creating an COVID-19 vaccine or monoclonal antibody infusion roster.
List itemCOVID-19 vaccine:CMS-1500 (02/12) examplepdf -- Use this example of how to complete the revised form CMS-1500 (02/12) when roster billing claims for the COVID-19 vaccine on and after December 11, 2020.
List itemCOVID-19 monoclonal antibody infusion: CMS-1500 (02/12) example pdf -- Use this example of how to complete the revised form CMS-1500 (02/12) when roster billing claims for COVID-19 monoclonal antibody infusions on and after November 10, 2020.
List itemInfluenza virus vaccine roster pdf -- here is a roster to use to capture patient information when creating an influenza virus vaccine roster.
List itemInfluenza virus vaccine - sample CMS 1500 (02/12) pdf -- use this example to learn how to complete the CMS-1500 (2/12) form when roster billing claims for influenza.
List itemPneumococcal pneumonia virus vaccine roster pdf -- here is a roster to use to capture patient information when creating a pneumococcal pneumonia virus vaccine roster.
List itemPneumococcal pneumonia virus vaccine - sample CMS-1500 (02/12) pdf -- use this example of how to complete the CMS-1500 (02/12) form when roster billing claims for pneumococcal pneumonia virus vaccine.
Overpayment
List item Extended repayment schedule for corporation or group formpdf -- this document is required to consider an extended repayment schedule request for a corporation or group.
List item Extended repayment schedule for sole proprietor form pdf -- this document is required for sole proprietors who wish to request an extended repayment schedule.
List itemReturn of monies voluntary refund form pdf -- this form is required to provide claim specific information for provider-advised overpayments.
List item Request for immediate offset form pdf -- use this interactive form when requesting immediate offset of overpayments.
Prior authorizations
List itemPrior authorization request (PAR) for repetitive scheduled non-emergent ambulance transports (RSNAT) Medicare Part B fax/mail coversheet pdf -- The supplier must submit the PAR before the service is provided to the beneficiary and before the claim is submitted for processing Learn more about the overall PAR RSNAT process.
List itemPAR hospital outpatient procedures Medicare Part A fax/mail coversheet pdf -- The hospital outpatient department (OPD), or provider on behalf of the hospital OPD, must submit the PAR for certain hospital OPD services. Learn more about the overall PAR OPD process.
List itemPAR hospital OPD Medicare Part A expedited fax/mail coversheet pdf Note: This form should only be submitted if it is determined that a delay could seriously jeopardize the beneficiarys life, health, or ability to regain maximum function.
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).
Secure provider online tool (SPOT)
SPOT enrollment forms
Update information
List item SPOT update form for organizationspdf (Add/remove NPI/PTANs within account)
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.