Fillable FSCO 0433415 SPOT enrollment form

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FSCO 0433415 SPOT enrollment form

On average this form takes 9 minutes to complete

The FSCO 0433415 SPOT enrollment form form is 2 pages long and contains:

  • 1 signature
  • 7 check-boxes
  • 30 other fields

Country of origin: OTHERS
File type: PDF

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medicare.fcso.com
Page 1 of 2
Form revised 7/25/2019
SPOT enrollment form for new provider organizations
Please complete this form for enrollment to SPOT (Secure Provider Online Tool), First Coast Service Options’
internet portal. All fields marked with * are required and must be completed or the request will be rejected.
This form is for organizations to designate who the approver and backup approver will be. Individuals designated by
their organization as approvers and backup approvers must register in EIDM (Enterprise Identity Management
System) once they receive approval from First Coast. Go here for more on how to register in EIDM -- https://
medicare.fcso.com/faqs/answers/241528.asp. Note: Those requesting end user access to SPOT are not required
to complete this form.
*Line of business:
Part B (Professional)
*State:
BILLING PROVIDER INFORMATION
APPROVER(s) DESIGNATION
FL
Part A (Institutional)
PR
USVI
*Contact fax number:
*State:
*ZIP Code:
*NPI
:
*Tax ID #/EIN/SSN (all nine digits):
LINE OF BUSINESS/LOCATION
*PTAN:
*Approver F
irst Name:
*Approver Last Name:
*Approver email:
Backup Approver First Name:
Backup Approver Last Name
Backup Approver email:
*Provider legal business name:
*Contact name:
*
Contact phone number:
*Street address:
*City:
Select one
medicare.fcso.com
Page 2 of 2
Form revised 7/25/2019
ATTESTATION
Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing
any final decision made by CMS under this document.
This document shall become effective when signed by the provider. The responsibilities and obligations contained in this
document will remain in effect as
long as Medicare claims are submitted to the A/B MAC, DME MAC, CEDI, or other
contractor if designated by CMS.
Either party may terminate this arrangement by giving the other party thirty (30) days written notice of its intent to
terminate. In the event that the notice is mailed, the written notice of termination shall be deemed to have been given upon
the date of mailing, as established by the postmark or other appropriate evidence of transmittal.
AUTHORIZED OFFICIAL SIGNATURE REQUIREMENTS
By signing below I certify that I have been appointed an authorized official to whom the provider has granted the legal
authority to enroll it in the Medicare Program, to make changes and/or updates to the provider's status in the Medicare
Program (e.g., new practice locations, change of address, etc.), and to commit the provider to abide by the laws,
regulations, and the program instructions of Medicare. I authorize the above listed entities to communicate electronically
with First Coast on my behalf.
By signing below the provider confirms they have read and agree with the provider EDI agreement, the CMS’ obligations,
and the attestation sections of this document and above signature requirements.
* Authorized official signature: *Date:
* Name and title of authorized official (Print):
Email: MedicareEDI@fcso.com | Fax: (904) 361-0470 | Mail: First Coast Medicare EDI, P.O. Box 44071 Jacksonville, FL 32231-4071
Once you complete the form and sign it, click the Submit button below to email the form to First Coast Service
Options' SPOT help desk, or you can fax or mail a printed version of the completed form using the information below.
PTAN NPI
ADDITIONAL NPI/PTAN ASSOCIATIONS
Please provide in the fields below any additional NPI/PTAN combinations that you want associated with your organization
and the Tax Identification Number listed above on your registration form. An example would be to include the NPI/PTAN
combination of a rendering physician within your organization, which SPOT could use to return a comparative billing report
(CBR) specific to that physician and their specialty. These combinations, which are optional, will be validated as well
during the time your request is evaluated.
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FSCO 0433415 SPOT enrollment form

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Completed 26 September 2019

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