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ENROLLMENT FORM
Category(s) of Service:
If you are ALREADY ENROLLED and need to change your address,
click here
.
Provider Enrollment & Maintenance
If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or
click here
to send us an email. Please note, the
Medicaid Pending Provider Listing
lists all applications that are in process, and the
Medicaid Enrolled Provider Listing
lists all enrollments that have been approved.
General Instructions
for the Enrollment Form
Complete
ALL
items on the form
unless
otherwise instructed below. Failure to complete all required fields will result in your enrollment form being returned to you which may have an impact on the enrollment effective date.
Required documents must be valid on the application date and continuously valid through the current date.
An original signature is required. Initials or rubber-stamped signatures will not be accepted.
Type or legibly print in black or blue ink. Do not use red ink, nor white-out. All attachments will be scanned so they must be legible and on standard 8.5 x 11 paper in good condition.
Keep a copy of all documents submitted, as requests for copies cannot be honored.
Valid telephone numbers are required for each service address.
Do Not
submit documentation containing recipient information with your application (e.g., paper claims forms, recipient insurance verification documents, etc.).
Additional Instructions
for the Enrollment Form
Category(s) of Service:
Enter the applicable 4-digit code(s) on the Enrollment Form
Association Types:
Enter the letter (B, F, H, I, M, P or U) which best corresponds to the individual's role.
Note: ALL lifestyle coaches providing NDPP services for your organization must be listed in Section 5 of the application as a I-Employee/Lifestyle Coach
B: Board of Directors Member
F: Facility Administrator
H: Compliance Officer
I: Employee/Lifestyle Coach
M: Managing Employee
P: Supervising Pharmacist
U: Laboratory Director
Requirements & Additional Forms
Application Fee Exemption - form #520101
Electronic Funds Transfer (EFT) Authorization - form #701101
(NOT REQUIRED for revalidation if EFT is already in place and no change is requested or if you are enrolling as a Managed Care Only non-billing provider)
ETIN Certification Statement for New Enrollments - form #490602
(Not required for revalidation, reinstatement, or reactivation). If you already have an existing ETIN that you wish to affiliate with, submit the Certification Statement for Existing ETINs (EMEDNY 490601)
after you receive your Provider ID.
This form is available
here
.
Group Member Affiliation/Disaffiliation Request - form #610202
(Each Member MUST complete this form). NOT REQUIRED if you are enrolling as a Managed Care Only non-billing provider)
Prior Conduct Questionnaire - form #431001
If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
Authorization from the Office of Children and Family Services
For Changes of Ownership ONLY
Provide proof that a Change of Ownership has occurred. Examples of proof include but are not limited to a
Bill of Sale, Transfer of Ownership, Operating Agreement, Stock Purchase Agreement, etc.
IRS Assignment Letter indicating the FEIN and Applicant Name on the Enrollment Form
(W-9 NOT ACCEPTABLE). IRS Assignment Letter (Form: SS-4) can be obtained by going to IRS.Gov or call IRS at 1-800-829-4933
Proof of current license / registration
Examples: 1) Copy of license with future expiration date, 2) Copy of license registration/renewal, or 3) Printout of your license status from the licensing agency’s website.
Proof of current registration with the NYS Education Department
For private practicing groups located in New York and established as PC's, LLC's, LLP's or PLLC's: Proof of current registration with the NYS Education Department. (Note: this is
not
the Department of State). If your copy of the registration is not available, visit
http://www.op.nysed.gov/opsearches.htm#.eng
, Use the
"Search for Professional Business Entity, by Name:"
search feature, print your
"Business Entity Information"
summary and submit it with your Medicaid enrollment form
Provider Compliance Certification -
Certification of a Provider Compliance Program
may be
required. By signing the
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID,
you (or the entity) certify that, where required, you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider Compliance Program, please go to the program website at
https://omig.ny.gov/compliance/compliance
.
Maintenance Forms
Change of Address - form #610101
Complete on the
PE Portal
Change of Address - form #610601
Disclosure Form for Businesses - form #380101
Disclosure Form for Groups - form #380102
Disclosure Form for Institutions - form #380103
Disclosure Form for Practitioners - form #380104
Complete on the
PE Portal
EFT Attestation Form - form #701102
Complete on the
PE Portal
Group Member Affiliation/Disaffiliation Request - form #610202
(Each Member MUST complete this form). NOT REQUIRED if you are enrolling as a Managed Care Only non-billing provider)
Ordering/Prescribing/Referring/Attending FAQs
Prior Conduct Questionnaire - form #431001
Complete on the
PE Portal
If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
Status Change Form for Groups - form #426402
Default Electronic Transmitter Identification Number (ETIN) Selection - form #401103
Complete on the
PE Portal
Provider ID Request Form - form #610801
Complete on the
PE Portal
Request to Disaffiliate/Delete an ETIN - form #401102
Complete on the
PE Portal
Taxpayer Information Update - form #610501
Complete on the
PE Portal
Mailing Instructions
Keep a copy of all documents submitted, as requests for copies will not be honored.
Send the completed enrollment form, required documents and additional forms to:
STANDARD MAILING
EXPEDITED / PRIORITY MAILING
eMedNY
P.O. Box 4603
Rensselaer, NY 12144-4603
eMedNY
ATTN: Box 4603
327 Columbia Turnpike
Rensselaer, NY 12144
Last Updated: 3/2024
Supplemental Information