Home | Glossary | Site Map

Search 
What's New Information Provider Manuals Self Help Training Contacts NYHIPAADESK
 
What's New
Information
Overview
Provider Enrollment Forms
DOH Medicaid Update Website
Notifications
eMedNY Paper Forms
Frequently Asked Questions
Formulary File
Online License Verification
Posting Provider List
Disqualified Provider List
Deceased Provider List
Fraud Alerts
Provider Manuals
Self Help
Training
Contacts
NYHIPAADESK
 
Provider Enrollment Forms

Adobe Acrobat Reader required to view documents available for download from www.adobe.com

 

Fee For Service Provider Forms
Download and submit any program...

Electronic/Paper Transmitter Identification Number (TSN/Provider)


Security Packets For Direct System Access

Real-Time (PC-to-Host, CPU-to-CPU)
Security Packet A

Batch (FTP, Electronic Gateway(BBS))
Security Packet B


Portable X-ray Enrollment Packet


Physician Enrollment Packet

HIV Enhanced Fee Payment

Medicaid Obstetrical and Maternal Services (MOMS) Program

Preferred Physicians And Children (PPAC) Program (Physician)


Pharmacy Enrollment Packet

Electronic/Paper Transmitter Identification Number (TSN/Provider)

Out of State Pharmacy


Nurse Practitioner Enrollment Packet

Medicaid Obstetrical and Maternal Services (MOMS) Program

Preferred Physicians And Children (PPAC) Program (Nurse)


Registered Physician's Assistant Enrollment Packet


LPN/RN Nursing Enrollment Packet


Service Bureau Enrollment Packet

Electronic Transmitter Identification Number (TSN/Service Bureau)


Podiatrist Enrollment Packet


Dentist Enrollment Packet


Clinical Psychologist Enrollment Packet


Clinical Social Worker Enrollment Packet


Chiropractor Enrollment Packet


Therapist Enrollment Packet


Nurse Registry Enrollment Packet


Self Employed Optician-Optometrist Enrollment Packet


Hearing Aid Dealer Enrollment Packet


Transportation Enrollment Packet


Midwife Enrollment Packet

Medicaid Obstetrical and Maternal Services (MOMS) Program


Group Enrollment Packet


DME Enrollment Packet


Optical Establishment/Salaried Optician/Optometrist Enrollment Packet


Laboratory Enrollment Packet

 

 

Provider Maintenance Forms

Provider ID Request Form

CLIA Information

Personal Identification Number

Supervising Pharmacist Agreement

Collaborating Physician Form

Supervising Physician Certification

Application as a Specialist

Fee for Service Address Change Form

Rate Based Change of Address Form

Out-of-State Hospital Enrollment Package Request Form

Request for Participation Group

DEA Update Form

Medicare Info Update Form

Tax Update Form

Electronic Remittance Request Form

Electronic Prior Approval Request Form

Paper Remittance Sort Request Form

Electronic Funds Transfer (EFT) Enrollment Form

Pended Claim Recycle Request Form

Request to Disaffiliate/Delete an ETIN

Medically Fragile Children PDN Rate Enhancement

Trading Partner Agreement

New York State Department of Health Home | Glossary | Site Map
webmaster@emedny.org | Privacy Policy