ENROLLMENT FORM

Category(s) of Service: 0267

If you are ALREADY ENROLLED and need to change your corporate or correspondence address, click here.

  Application Fee is REQUIRED. Click here for more information.  


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Provider Index > Assisted Living Program (ALP)

Provider Enrollment & Maintenance



Serves persons, medically eligible for nursing home placement, in a less medically intensive, lower-cost setting. Persons with Medicaid coverage must have their ALP services approved in advance by their Local Social Services District.


Complete this Enrollment Form if you are:
  1. Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
  2. Responding to a letter instructing you to REVALIDATE your enrollment, or
  3. Seeking REINSTATEMENT or REACTIVATION of your previous enrollment, or
  4. Reporting an OWNERSHIP CHANGE, or
  5. Reporting a RECEIVERSHIP

INSTITUTION Enrollment Form

Last Updated: 9/2017


Supplemental Information

If you have any questions or concerns, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email.