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Clerical reopenings -- submit minor corrections outside of the appeals process online using SPOT, or by calling the IVR (Interactive Voice Response).
3rd level: Forms pertaining to a level 3 appeal -- a request for a hearing by an Administrative Law Judge
Medicare Part B PWK fax/mail coversheet -- Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim - valid for forms received through March 31, 2018.
Medicare Part B PWK fax/mail coversheet -- Use this form for voluntary submission of supporting documentation with a version 5010 electronic claim - effective for forms received on and after April 1, 2018.
EDI 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
Influenza virus vaccine roster -- here is a roster to use to capture patient information when creating an influenza virus vaccine roster.
Influenza virus vaccine - sample CMS 1500 (02/12) -- use this example to learn how to complete the CMS-1500 (2/12) form when roster billing claims for influenza.
Pneumococcal pneumonia virus vaccine roster -- here is a roster to use to capture patient information when creating a pneumococcal pneumonia virus vaccine roster.
Pneumococcal pneumonia virus vaccine - sample CMS-1500 (02/12) -- 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)
Extended repayment schedule for corporation or group form -- this document is required to consider an extended repayment schedule request for a corporation or group.
Extended repayment schedule for sole proprietor form -- this document is required for sole proprietors who wish to request an extended repayment schedule.
Request for immediate offset form -- use this interactive form when requesting immediate offset of overpayments.
Provider 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).
CMS’ Beneficiary Notices Initiative (BNI) -- links to commonly-used beneficiary notices such as ABNs, FFS and HINNs.
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.