ENROLLMENT FORM

Category(s) of Service: 0160

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.  

Provider Index > Hemodialysis Center (freestanding) > Out of State

Provider Enrollment & Maintenance

Out of 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

• 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 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     0160
  
  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.
  • Check Receivership if the provider is enrolled and a Receiver has been appointed

  
  Effective Date: If your license/operating certificate 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 authorization. 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: Complete if Applicant possesses either of these
  
  # Of Beds: Leave Blank
  
  Service Address: List all addresses where services are provided.
  
  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
  • Application Fee
  • DEA Certificate     Copy of your DEA certificate or web based printout from the office of Diversion Control website at https://www.deadiversion.usdoj.gov/webforms/dupeCertLogin.jsp if you are licensed to prescribe or dispense controlled substances. If employed by an institution and authorized to use the Institution's DEA, submit a copy of that DEA and proof of the suffix/identifier assigned to you by the Institution
  • 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
  • License issued by the Home State Licensing Agency    
  • Medicare Enrollment is Required     (except if a licensed OMH Day Treatment ONLY)

  • 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 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"
  • 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).

  
  

  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.
• 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).
• Mailing Instructions
  1. Keep a copy of all documents submitted
  2. Send the completed enrollment form, required documents and additional forms to:

  STANDARD MAILING	EXPEDITED / PRIORITY MAILING
  eMedNY P.O. Box 4603 Rensselaer, NY 12144-4603	eMedNY ATTN: Box 4603 327 Columbia Turnpike Rensselaer, NY 12144

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.