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Form revised 7/25/2019
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.
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.
click to sign
click to edit