eMedNY Paper Forms

Please note that these sample forms are intended to provide you with advanced planning information. These samples are not to be used for live submission of information to NY Medicaid.

Paper submission of claims and requests to New York Medicaid must be presented on original forms.

Claim Forms

USERS

Dental, Transportation

Fee for Service

Pharmacy

Rate Based


	Prior Authorization Forms
	Prior Approval Roster Request Form Prior Authorization Form for Out-of-State Nursing Homes - Title XIX Program Order/Prior Approval Request - Pharmacy/DME, Nursing, Eye Care, Physician Order/Prior Approval Request - Dental Services Hearing Aid - Order/Prior Approval request High/Special Level of Care - Determination of Medical Eligibility Prior Approval Change Request Form Prior Approval Change Request Form Instructions Provider Fax Coversheet Form Provider Fax Coversheet Instructions


	Electronic Attachment Scanning Form and Instructions
	Electronic Attachment Scanning Form Electronic Attachment Scanning Form Instructions

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This website is provided as a service for providers and the general public, as part of the offerings of the electronic Medicaid system of New York State. You'll be able to find helpful manuals and reference material, and get answers to questions about New York Medicaid. The site is updated regularly to meet the ever-growing needs of the New York State provider community. If you need help finding what you're looking for, please visit our Site Map, use the search above, or you can contact us directly for assistance.

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