New coversheet for hardcopy UB-04 submissions

First Coast has developed a new coversheet, JN Hardcopy Request, for submissions of the hardcopy UB-04 form. You should include this new coversheet when mailing in hardcopy UB-04 forms to provide the state and reason for the hardcopy claim submission. This coversheet will assist First Coast with efficiently processing your request.

Note: If you are a paper provider and no other exceptions apply to you, please select Administrative Simplification Compliance Act (ASCA).