Category(s) of Service: 0264

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

click here.

Include the DOH Letter which waives the application fee for your LDSS

Provider Index > Community First Choice Option (CFCO)

Provider Enrollment & Maintenance

A Local Department of Social Services enrollment (LDSS) for CFCO Services
The LDSS will coordinate and reimburse CFCO services directly to providers for the following services, and will be available 01/01/2020:

Vehicle Modification
Environmental Modification
Home Delivered Meals
Assistive Technology
Community Transitional Services
Moving Assistance
Skill Acquisition, Maintenance and Enhancement (SAME)

Complete this Enrollment Form if you are:

Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
Responding to a letter instructing you to REVALIDATE your enrollment, or
Seeking REINSTATEMENT or REACTIVATION of your previous enrollment, or
Reporting an OWNERSHIP CHANGE, or
Reporting a RECEIVERSHIP

INSTITUTION Enrollment Form

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
Choose only ONE of the following options & check the corresponding box on the top of the Enrollment Form
- Check Billing Provider - For additional information related to program billing instructions please visit https://omh.ny.gov/omhweb/adults/supportedhousing/supportedhousingguidelines.html
Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form 0264
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.
- Check Receivership if the provider is enrolled and a Receiver has been appointed
Effective Date: If your Authorization was issued within the past 90 days AND has an effective date of more than 90 days ago, you may use the effective date of the license. Otherwise, the effective date must be less than or equal to 90 days ago.

FEIN: Federal Employer Identification Number is required

NY Medicaid ID: Complete if either the Revalidation, Change of Ownership, Reinstatement/Reactivation or Receivership box was checked. NY Medicaid ID is 8-digits

DBA: Optional

Control of Facility Code: Click here for the list of codes

DEA or NYS Cont Subs Lic # & Dates: These fields are not required.

# of Beds: Leave Blank

Service Address: List the address where services will rendered. This address will appear on you Local District Commissioners Approval Letter.

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
PLEASE NOTE: Only complete applications containing all requirements and additional forms will be accepted for processing. Applications with missing or incomplete information will be rejected and returned
- 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.
- 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.
- DOH Letter which waives the application fee for your CFCO District
- 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 #610601
- Disclosure Form for Institutions - form #380103
- EFT Attestation Form - form #701102
- 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 Institutions - form #436602

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:

The LDSS MMIS Application Shared Mailbox
This mailbox is on the Health Commerce System to protect personal and confidential information included in the MMIS applications. The link for the Health Commerce System is: https://commerce.health.state.ny.us/public/hcs_login.html NOTE: You must have an active HCS account to access the system. Once logged in, click All Applications from the drop-down menu and choose Secure File Transfer.

Once you launch the Secure File Transfer, a screen appears giving you the option of "Send Package".
Click on the icon next to the "TO:" box, (that will pull up a search field box).
Then type "LDSS MMIS" into the search box (that will pull up the icon for the LDSS MMIS Application Shared Mailbox, which you then should select).
You should now see <To: LDSS MMIS Application Shared Mailbox> at the bottom of the screen.
Click on OK and it will bring you to the "new package screen" that will allow you to send the application and required documentation as attachments via secure e-mail.

For routine questions without public information, e-mails can be sent to: LDSS.MMIS.Applications@health.ny.gov.

Last Updated: 12/2021

Supplemental Information

B: Board of Directors Member		F: Facility Administrator		H: Compliance Officer		I: Employee/Lifestyle Coach
M: Managing Employee		P: Supervising Pharmacist		U: Laboratory Director