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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.
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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.
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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 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.
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 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.
Medicare Secondary Payer (MSP)
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 item Request for immediate offset form pdf -- use this interactive form when requesting immediate offset of overpayments.
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.