ENROLLMENT FORM

Category(s) of Service: 0560

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

  Application Fee is NOT Required  


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Provider Index > Clinical Social Worker > Individual Billing Medicaid

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

PRACTITIONER Enrollment Form

Last Updated: 3/2015


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.