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This interactive tool provides the basic guidelines for completing the data element requirements for the CMS-1500 claim form.

This roster may be used to capture patient information when creating an influenza virus vaccine roster.

This roster may be used to capture patient information when creating a pneumococcal pneumonia virus vaccine roster.

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.

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.

This roster may be used to capture patient information when creating an COVID-19 vaccine or monoclonal antibody infusion roster.

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.

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.

Use this form before doing a hardcopy claim submission.

Use this form to request assistance from First Coast to resolve an overlapping claim.