51103
51103
Email address may be used for enrollment processing response and will be added to Medicare EDI listservs.
Please complete this form and return it to First Coast Service Options to update the information we
have on file to mail you EDI-related documents.
All fields marked with an * are required. Please print clearly.
* Current Legal Business Name:
All Submitter IDs for the same organization will be updated.
Change information on file to (check only those that apply):
Mailing Address:
Contact Person:
Contact Person's Telephone Number:
Contact Person's Fax Number:
Contact Person's Email Address:
* Line of Business:
Part A (Institutional)
Part B (Professional)
Tax ID:
Current Fax Number:
EDI Submitter ID Update Request Form
* Current EDI Trading Partner/Submitter ID:
City:
State: Zip Code:
SIGNATURE:
Providers: The Authorized Official signing this form should be an AUTHORIZED OR DELEGATED OFFICIAL
that was listed on the Medicare Enrollment Application (CMS-855).
Signature: Date:
Printed Name:
Title:
FP167N (R10-19)
*Contract/State (required):
Complete form, sign and date, and return all pages to:
Email: MedicareEDI@fcso.com
Fax: (904) 361-0470
Post: First Coast Medicare EDI
P.O. Box 3703
Mechanicsburg, PA 17055-1861
