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Request for Provider Reports (#610901)

This form may be used by enrolled providers to request information on their NY Medicaid file. Please check below the report(s) you are requesting. Please provide us with both your email and your mailing address below. If you prefer not to fill this out online and rather fill out the pdf and mail it in, you can click here to fill out the form.

Please be advised that requests for reports will be processed no more than every six(6) months for the same provider.


Requested Report(s):



Request Details:


Date of Request:

FROM:     TO:
Provider Name:
Provider Email:
Phone Number:
NPI:    (If exempt, enter "EXEMPT" in field)
MMIS ID
(only if NPI exempt)


MAILING ADDRESS
Name/Attention:
Street:
City:    State:      Zip:
How would you like us to send your report(s)?         


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