Last Modified: 9/5/2024
Location: FL, PR, USVI
Business: Part A, Part B
It is important that you use the most recent version of any EDI form when enrolling for EDI services or updating your existing EDI status. Please carefully review the following block-by-block instructions to ensure successful completion.
Note: The following screenshots are for instructional purposes only and cannot be completed and submitted for enrollment.
This is a required block. The form will be returned if these fields are not completed accurately.
• Select one from each drop-down depending on your location and the line of business you submit claims for.
• Type the current SPOT submitter ID.
• Type the current legal business name.
• Type the correspondence fax number.
• Type the complete mailing address for correspondence.
At least one completed field is required. Complete only the information that needs changed from the existing SPOT account information.
Updated legal business name
• To change the legal business name, type the new legal business name.
Updated Tax ID
• To change the organization’s Tax ID, type the new Tax ID. This does not apply to a change of ownership. If there is a new Tax ID because of a change of ownership, the new company must request a new submitter ID. Submitter IDs are not transferrable.
Updated contact person’s name and telephone number
• To change the contact person information, type the new contact person’s full name and complete telephone number.
Updated address
• To change the organization’s address, type the new street address, City, State, and ZIP code.
Updated Approver
• To change the organization’s office approver, type the new approver’s first name, last name, and email address.
Updated Backup Approver
• To change the organization’s office backup approver, type the new backup approver’s first name, last name, and email address.
This is a required block. The form will be returned if the required fields are not completed accurately.
• Review the entire form to verify the information provided is accurate and complete.
• Enter an authorized digital signature or sign after printing. If using the digital signature option, the electronic signature must show the date and time the form was signed. Do not type in this field. Typed signatures in any font will be returned.
• Enter the date the form was signed. The date must be a full month, day, and year.
• Type the printed name of the person signing the form.
• Type the professional title of the person signing the form.
• Type the contact person’s email address and telephone number.
• Print the form, if needed.
• If a digital signature was not completed, sign in the written signature block with a black or blue ink pen. Only wet or digital signatures as described above are accepted. Signature stamps will be returned.
• Wait for the notification fax/letter advising that the form has been processed.
• The business day after your notification is received, make the necessary changes in the
IDM system.
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.