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ENROLLMENT FORM

Category(s) of Service: 0572

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

  Application Fee is WAIVED
For a limited time, New York State (NYS) Medicaid will waive the initial Medicaid enrollment application fee for all newly enrolling National Diabetes Prevention Program (NDPP) service provider applications. This application fee waiver is made available via a grant that was awarded to NYS by the Centers for Disease Control and Prevention (CDC) to support the establishment of new Diabetes Prevention Program delivery organizations, and increased participation amoung high-burden populations.


Print Instructions

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

Last Updated: 11/2019


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.