ENROLLMENT FORM

Category(s) of Service:
0164 - EI Services, OR
0265 - EI Case Management
* TO PROVIDE BOTH SERVICES and CASE MANAGEMENT, LIST BOTH 0164 AND 0265 ON FORM


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

  Application Fee MAY BE REQUIRED. See Requirements & Additional Forms for Details  


Print Instructions

Provider Index > Early Intervention Program (EI)

Provider Enrollment & Maintenance



Provides therapeutic and support services to children under age 3 (and their families) who have a confirmed disability or established developmental delay in one or more areas of development.


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.