Last Modified: 6/7/2019
Location: FL, PR, USVI
Business: Part A, Part B
Did you check only one box on page 2 (basic information)?
• Yes
Did you fill in the “required sections” denoted to the right side of the box you checked?
• Yes
Did you provide the requested information for the supplier to whom benefits are being reassigned, or reassignment is being terminated?
• Yes
Did you denote “pending” in the Medicare identification number block on your application if the supplier’s initial enrollment application was submitted concurrently with this application?
• Yes
Note: The supplier’s name as reported to the IRS must match what was reported on the supplier’s CMS-855B when it enrolled. The National Provider Identifier (NPI) in this section is the NPI associated with the group.
Did you complete all portions of this section?
• Yes
Did you denote “pending” in the Medicare identification number block on your application if your initial enrollment application is being submitted concurrently with this reassignment application?
• Yes
Note: The NPI in this section is the NPI associated with the individual who is reassigning benefits.
Did you indicate the Primary Practice Location that the individual practitioner will render services most of the time?
• Yes
• The supplier’s name as reported to the IRS must match what was reported on the supplier’s CMS-855B when it enrolled. The National Provider Identifier (NPI) in this section is the NPI associated with the group.
Did you complete section 5 (on page 3), with the contact person information?
• Yes
Section 6
Did the individual practitioner complete and sign (in ink) section 6A on Page 3?
• Yes
Note: All signatures must be originals.
Did the authorized or delegated official complete and sign (in ink) Section 6B on Page 3?
• Yes
• All individuals who allow another supplier to receive payment for their services must submit a signed reassignment of benefits statement. All signatures must be originals.
The following chart describes when and how First Coast Service Options will contact providers based on the contact information provided in your enrollment application.
Contact type |
During the enrollment process |
Contact Fax |
Used as a first contact for all requests for additional information and to notify the applicant of the final status of the application when a CMS-855B is not simultaneously submitted. |
Contact Address |
Used as a contact for all requests for additional information when a fax number is not provided or a fax number is not valid and a CMS-855B is not simultaneously submitted. |
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.
