ENROLLMENT FORM

Category(s) of Service: 0572

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

  Application Fee is REQUIRED. Click here for more information.  

Provider Index > Community Based Organizations (CBO)

Provider Enrollment & Maintenance

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

BUSINESS Enrollment Form

• 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 cover the application date and be continuous through the current date.
  • Completion of signature field is required and must be original. 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.
  • Valid Telephone numbers are required for each service address.
• Additional Instructions for the Enrollment Form
  Choose only ONE of the following options & check the corresponding box on the top of the Enrollment Form

  • Check Billing Provider - If the applicant/provider intends on Billing NYS Medicaid
  • Check Managed Care Only (Non Billing) - If the applicant/provider is contracted with a Managed Care and is required to enroll with NYS Medicaid per the 21st Century Cures Act.

  
  Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form     0572
  
  Choose ONE Application Type and check the corresponding box on the Enrollment Form:

  • Check New Enrollment if the NPI or Provider listed is not currently enrolled in NYS Medicaid
  • Check Revalidation if the NPI or Provider is currently enrolled and you were notified that Revalidation is required per 42 CFR, Part 455.414. The Provider ID can be found on the Revalidation Letter you received
  • Check Change of Ownership to comply with 42 CFR, Part 455.104 - Proof that a Change of Ownership has occurred is required. See Requirements and Additional Forms (below).
  • Check Reinstatement/Reactivation if the provider was previously enrolled but is not currently active.
    Please note: You will be at financial risk if you render services to Medicaid beneficiaries before successfully completing the enrollment process.

  
  NPI: This field is required.
  
  License # Fields: Leave Blank
  
  DBA Name: Not Applicable
  
  DEA Number & Dates: Not Applicable
  
  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 ($688)
  • Application Fee Exemption - form #520101   
  • Electronic Funds Transfer (EFT) Authorization - form #701101    NOT REQUIRED IF:
    - submitting a revalidation, reinstatement/reactivation (i.e., if EFT is already in place and no changes are requested).
    - you answered "No" to the question, "If affiliated with a Group, do you have a Private Practice as well?" on page 2 of the Enrollment Form.
  • ETIN Certification Statement for New Enrollments - form #490602    (NOT REQUIRED for revalidation or reinstatement/reactivation, or if you are enrolling as a Managed Care Only non-billing provider). 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.
  • NDPP Recognition Attestation - form #434901    To receive payments for NDPP Services, complete this form and include any and all relevant documents received from the CDC stating that you have achieved National Diabetes Prevention Recognition Program (DPRP) certification.
  • 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.
  • 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

  
  

  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   
  • Disclosure Form for Businesses - form #380101   
  • EFT Attestation Form - form #701102   
  • NDPP Recognition Attestation - form #434901    To receive payments for NDPP Services, complete this form and include any and all relevant documents received from the CDC stating that you have achieved National Diabetes Prevention Recognition Program (DPRP) certification.
  • 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.
  • Status Change Form for Businesses - form #436703   
• Mailing Instructions
  1. Keep a copy of all documents submitted
  2. 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

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.