Last Modified: 12/11/2020
Location: FL, PR, USVI
Business: Part A, Part B
Physician assistants (PA) must meet all of the following criteria to provide services for Medicare beneficiaries:
• Licensed by the state in which he or she practices as a physician assistant
• Graduate of a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistants (or its predecessor agencies) or passed the national certification examination administered by the National Commission on Certification of Physician Assistants
• Signed and dated Certification Statement -- all signatures must be original and signed in ink (blue ink preferred). Stamped, faxed, or copied signatures will not be accepted.
Note: If you submitted your application through internet-based PECOS, you may sign the application electronically or you must submit your paper Certification Statement within fifteen days of your electronic submission.
• Include copies of the following supporting documents:
• A notarized copy or a certified “true copy” of the practitioner’s state medical license:
• A notarized copy must include the stamp that states “official seal” and the name of the notary public as well as the state, county, and date the notary’s commission expires.
• A certified “true copy” of an original document has a raised seal that identifies the state and county in which it originated or is stored.
Note: A provider/supplier located in Puerto Rico or U.S. Virgin Islands must include a copy of his or her Letter of Good Standing. The letters for Puerto Rico providers/suppliers will be considered valid if it was issued within 12 months of First Coast Service Options’ (First Coast’s) receipt of the enrollment application. The letters for U.S. Virgin Islands providers/suppliers will be considered valid if it was issued within six months of First Coast Service Options’ (First Coast’s) receipt of the enrollment application.
• Certificate of completion, transcript, and/or diploma from accredited educational program(s) required for certification and/or licensure (please refer to Qualification requirements section at the top of the page.)
Medicare may require additional documentation, when applicable, to validate key information contained within the enrollment application (e.g., name change, tax identification number, proof of citizenship) or to address specific issues that could adversely affect a practitioner’s potential eligibility for enrollment (e.g., adverse legal actions, financial relationships).
• Driver’s license
• Social security card
• Marriage license
• U.S. passport
• National provider identifier (NPI) verification from National Plan and Provider Enumeration System (NPPES) -- only durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers are required to submit this type of documentation
• Final adverse action documentation: Please include copies of legal documents associated with any final adverse action(s) taken against the provider as well as copies of any the legal documents showing its resolution (e.g., notifications, reinstatement letters).
Note: Documents containing a summary of the adverse actions taken or their resolution will not be accepted.
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