* Please Do Not Copy *
Medicare Part B Fax/Mail/esMD Cover Sheet
for Submitting UNSOLICITED Paperwork (PWK) Segments
Complete all fields then submit this form via the Electronic Submission of Medical Documentation (esMD) system or by fax/mail
to the applicable address or number provided at the bottom of the page. Complete ONE (1) Medicare Fax/Mail/esMD Cover
Sheet for each electronic claim for which documentation is being submitted. This form should not be submitted prior to filing the
claim. Please use ALL CAPS for your entries.
ACN: (Exactly as entered in the PWK loop on the claim): ICN:
Beneficiary: Last Name
First Name
MEDICARE ID:
Date(s) of Service: From
To
Total Claim Billed Amount:
Billing Provider’s Name:
Contact Name: Contact Phone Number:
NPI:
Total Number of Documentation Pages:
(including cover sheet):
Please provide a complete return mailing address along with any additional information needed here:
This document is intended solely for the use of the individual or entity to which it is addressed and may contain information that is
privileged, condential and exempt from disclosure under applicable law. If the reader of this notice is not the intended recipient
or individual responsible for delivering the message to the intended recipient, you are hereby advised that any dissemination,
distribution or copying of this information is strictly prohibited. If you receive this communication in error, please advise us by
telephone and destroy these papers.
Florida Puerto Rico
First Coast Service Options, Inc.
P.O. Box 2009
Mechanicsburg, PA 17055-0709
Fax: (904) 361-0838
U.S. Virgin Islands
First Coast Service Options, Inc.
P.O. Box 2004
Mechanicsburg, PA 17055-0704
Fax: (904) 361-0527
First Coast Service Options, Inc.
P.O. Box 2004
Mechanicsburg, PA 17055-0704
Fax: (904) 361-0828
medicare.fcso.com
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50004
50004
(R9/14/20)
