ENROLLMENT FORM

Category(s) of Service: 0268

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 > Children's Health and Behavioral Transformation

Provider Enrollment & Maintenance



Childrens BH Early and Periodic Screening and Diagnostic Testing (EPSDT), formerly known as SPA Services, are Behavioral Health and Health services available to children/youth under the age of 21 who are Medicaid eligible and meet medical necessity criteria. Applicants must meet the provider qualifications as specified in the Manual and will be designated by the State.

Children's Home and Community Based Services (HCBS) are designed to offer Medicaid eligible children/youth under the age of 21 who meet the target, risk and functional criteria, and their families, services and supports in the least restrictive environment to enable them to remain at home and in the community. Applicants must meet the provider qualifications as specified in the HCBS Manual and will be designated by the State.




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.