POE-AG membership form

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POE-AG -- Medicare membership form

By submitting this form, I agree, as a representative from a local or state medical society, provider organization, billing agency, or other specialty, to participate as a member of the First Coast Service Options’ (First Coast) Provider Outreach and Education Advisory Group (POE-AG).

As a member of this group, I also agree to be actively involved in the process of selecting topics and delivery methods for First Coast’s Medicare educational events, with the goal of enhancing educational outreach efforts. My involvement will include participation in a minimum of three meetings, per year, and to respond to First Coast’s periodic requests for input on its educational approach, topics, and tools.

Note: First Coast’s POE team will review all membership request forms and determine approval to ensure group membership is representative of First Coast’s provider population based on geographic diversity, specialties, and provider institutions served in the region.

In addition, I understand the following:

• First Coast, the Medicare administrative contractor (MAC) for Florida, Puerto Rico and the U.S. Virgin Islands, facilitates the POE-AG.

• There is no fee or reimbursement for participation in the POE-AG.

• Information about my participation in the advisory group (name and organization) will be posted on this website in the form of meeting minutes and membership list.

Please fill out the form below:

Full name:

Title/position:

Medical specialty:

Organization represented:

Phone number:

Fax number:

Email:

Mailing address:

City:

State:

ZIP Code:

Are you a member of another MAC POE-AG?

Yes No

Organizational focus

First Coast strives to involve representatives from a variety of specialties and organizations in the POE AG process. Please select all that apply to your organization:

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