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 cover the application date and be continuous through the current date.
Completion of signature field is required and must be original. 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.
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 - If the applicant/provider intends on Billing NYS Medicaid
Check Managed Care Only (Non Billing) - If the applicant/provider is contracted with a Managed Care and is required to enroll with NYS Medicaid per the 21st Century Cures Act.
Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form 0321 - DME Appliances or Supplies and Footwear, AND/OR 0323 - Oxygen Related Equipment
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
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.
Footwear: If enrolling to provide Prescription Footwear, you must employ a person credentialed as an orthotist, pedorthist or prosthetist, and include copy of License with application. **Indicate 0321 on the enrollment form.
Oxygen-Related Equipment: If enrolling to provide oxygen-related equipment, you must employ a licensed respiratory therapist, and include copy of License with application. **Indicate 0323 on the enrollment form.
Other DME Appliances and Supplies: If enrolling to provide DME appliances and supplies, not including footwear and/or oxygen-related equipment, indicate 0321 on the enrollment form. No staff certification is required.
DBA Name: If appropriate
DEA Number & Dates: Leave Blank
Service Address: Must be the same address as approved by Medicare and must be the physical location of your business
Association Types: Enter the letter (B, F, H, M, P or U) which best corresponds to the individual's role:
B: Board of Directors Member
F: Facility Administrator
H: Compliance Officer
M: Managing Employee
P: Supervising Pharmacist
U: Laboratory Director
Requirements & Additional Forms
A Site Visit It can be waived if 1) a site visit was conducted by Medicare or another state’s Medicaid or CHIP Programs within the past 12 months; OR 2) your State’s licensing agency has completed a site survey within the past 12 months. Please submit proof with your enrollment form if an eligible site visit has occurred
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
Medicare Enrollment is Required
Proof of Contract Supplier Status If located outside of NYS, DMEPOS Competitive Bid/Contract Suppliers should include Proof of Contract Supplier Status
Proof of current license / registration Examples: 1) Copy of license with future expiration date, 2) Copy of license registration/renewal, or 3) Printout of your license status from the licensing agency's website/Certification of Staff Member who qualifies you to provide Footwear or Oxygen- Related services if applying for those services.
ETIN Certification Statement for New Enrollments - form #490602 (NOT REQUIRED for revalidation or reinstatement/reactivation, or if you are enrolling as a Managed Care Only non-billing provider). 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 on eMedny.org under "Maintenance Forms"
OMIG Provider Compliance Certification - Confirmation notice for the OMIG Provider Compliance Program may be required. Visit www.omig.ny.gov to determine if the Applicant / Provider must comply. If yes, a copy of the confirmation notice (printed from the website) must be included with this application.
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