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Last Modified: 10/3/2020 Location: FL, PR, USVI Business: Part A, Part B

Paperwork (PWK) fax/mail/esMD coversheet

The PWK fax/mail coversheet was revised to remove the health insurance claim number (HICN) and replace it with "Medicare ID" as part of the Medicare Access and CHIP Reauthorization Act of 2015, which requires removal of the Social Security number-based HICN from Medicare cards.
As a result of this change, Medicare contractors shall accept only the new PWK fax/mail/esMD coversheets that contain "Medicare ID" effective April 2, 2018. Providers who downloaded PWK forms prior to April 2, 2018, should delete them and use only the new forms.
Note: if an “old” form is received it will not be processed. Prior versions cannot be accepted.
The revised PWK fax/mail/esMD coversheets are available through the links below:
Source: The Centers for Medicare & Medicaid Services Change Request 10124
Source: CR 10397
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.