EDI and SPOT enrollment forms

These enrollment forms are designed to be downloaded and completed using Adobe or typed online. Carefully follow the instructions and then email, fax, or mail a signed version of the completed form to us. 

EDI enrollment forms

• EDI Enrollment Form (8292)

  This form should be completed by providers using the SFTP connection and/or requesting access to the Fiscal Intermediary Shared System (FISS). Follow these instructions for completing the 8292 form.

• EDI Third Party Enrollment Form (8291)

  This form should be completed by billing services and clearinghouses using the SFTP connection to First Coast. This is also used by software vendors to setup for testing. Follow these instructions for completing the 8291 form.

• EDI Enrollment Affiliated Provider List

  This form is to enroll multiple group or solo providers with the EDI enrollment or SPOT enrollment process.

• EDI Submitter Update Request Form (FP167)

  This form is to change the address or contact information for an existing EDI Submitter ID. 

SPOT enrollment forms

• EDI SPOT Enrollment Form for provider offices (8292P)

  This form should be completed by providers requesting access to SPOT. Follow these instructions for completing the 8292P form.

• EDI SPOT Enrollment Form for billing service or clearinghouse (8291P)

  This form should be completed by billing services and clearinghouses requesting access to SPOT. Follow these instructions for completing the 8291P form.

• SPOT Migration List

  This form may be used by billing services and clearinghouses to request the conversion of multiple providers from an existing non-portal submitter ID to an existing SPOT submitter ID.

• SPOT Submitter ID Update Request Form (FP167P)

  This form should be completed by any organization already setup for SPOT to update your office approver, office back-up approver, legal business name, Tax ID, mailing address, and/or contact telephone number. Follow these instructions for completing the FP167P form.