NY Medicaid  
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Request for Provider Reports

  • This form may be used by enrolled providers to request information on the NY Medicaid file. Please check below the report(s) you are requesting.
  • Please be advised that requests for reports will be processed no more than every six (6) months for the same provider.
  • Up to 10 different providers can be included on this form. ("Provider Name" and "MMIS ID" fields are expandable.)

Requested Report(s):

Requestor Name: (your name)
Requestor Email:

Provider Name MMIS ID  


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