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Medicare participating providers/suppliers in Florida for Area 2, Part 1 enrolled with First Coast.

Medicare participating providers/suppliers in Florida for Area 2, Part 2 enrolled with First Coast.

Medicare participating providers/suppliers in Florida for Area 1, Part 1 enrolled with First Coast.

Medicare participating providers/suppliers in U.S. Virgin Islands Part 1 enrolled with First Coast.

Medicare participating providers/suppliers in U.S. Virgin Islands Part 2 enrolled with First Coast.

Medicare participating providers/suppliers in Puerto Rico Part 1 enrolled with First Coast.

Medicare participating providers/suppliers in Puerto Rico Part 2 enrolled with First Coast.

Participants agree to accept assignment for all covered services provided to Medicare patients. New physicians, practitioners, and suppliers may submit this form at the time of enrollment.