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LICENSE FOR USE OF "PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY" (CPT), FOURTH EDITION End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA).

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This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. For the most comprehensive experience, we encourage you to visit Medicare.gov or call 1-800-MEDICARE. In the event your provider fails to submit your Medicare claim, please view these resources for claim assistance.
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Forms

Modified: 3/12/2024
Medical records or other documentation for additional documentation response (ADR) letters may be returned via fax. Use this form as a fax coversheet. [CR 8436]
Modified: 6/23/2022
Find information on where to obtain and how to complete the CMS 1500 claim form.
Modified: 4/16/2024
This form is used by beneficiaries to authorize an individual to act as a representative in connection with a Medicare appeal.
Modified: 2/16/2024
This report is required of the Social Security Act. Failure to submit this report may result in a suspension of payments under the Medicare program and may affect your eligibility to participate in the Medicare program.
Modified: 5/18/2023
This roster may be used to capture patient information when creating an COVID-19 vaccine or monoclonal antibody infusion roster.
Modified: 2/16/2024
To consider an extended repayment schedule request for a corporation or group, the following documentation is required. [CR 9423]
Modified: 2/16/2024
Sole proprietors who wish to request an extended repayment schedule request must complete an extended repayment schedule request form. [CR 9423]
Modified: 6/23/2022
Use this example of how to complete the revised form CMS-1500 (02/12) when roster billing claims for the COVID-19 vaccine on and AFTER December 11, 2020.
Modified: 4/17/2024
The following provides access and/or information for many CMS forms. You may also use the search feature to more quickly locate information for a specific form number or form title.
Modified: 6/16/2022
Use this example of how to complete the revised form CMS-1500 (02/12) when roster billing claims for COVID-19 monoclonal antibody infusions on and AFTER November 10, 2020.
Modified: 4/7/2022
This roster may be used to capture patient information when creating an influenza virus vaccine roster.
Modified: 6/23/2022
Use this example of how to complete the revised CMS-1500 (02/12) form when roster billing claims for influenza virus vaccine for dates of service on and AFTER October 1, 2015.
Modified: 2/7/2024
Use this form for all overpayments. Options must be selected; if none are checked, an overpayment letter will be issued. Mail the form to the appropriate address included at the end of the form.
Modified: 4/7/2022
This roster may be used to capture patient information when creating a pneumococcal pneumonia virus vaccine roster. [First Coast Provider Outreach and Education]
Modified: 6/23/2022
Use this example of how to complete the revised form CMS-1500 (02/12) when roster billing claims for pneumococcal pneumonia virus vaccine on and AFTER October 1, 2015.
Modified: 2/16/2024
Use this interactive form when requesting immediate offset of overpayments. Fax the completed form to the number included within the form. [CR 7688]
Modified: 4/16/2024
This updated form is for an appeal and is not to be used when requesting a claim adjustment. Fill it out online, then print and mail it to the address indicated on the form.
Modified: 4/16/2024
Minor clerical errors or omissions can be corrected more quickly outside of the formal appeal process. Use this interactive form to help ensure your request is processed accurately.
Modified: 4/13/2024
Providers who require a copy of IRS form 1099-MISC may send a request, in writing, to First Coast.
Modified: 4/20/2024
Did you know that submitting an outdated or old form can cause a delay or even a rejection of your request? Use the correct form today to avoid processing issues.
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.