Category(s) of Service:

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

Provider Enrollment & Maintenance

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email. Please note, the Medicaid Pending Provider Listing lists all applications that are in process, and the Medicaid Enrolled Provider Listing lists all enrollments that have been approved.

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 be valid on the application date and continuously valid through the current date.
- An original signature is required. 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, as requests for copies cannot be honored.
- Valid telephone numbers are required for each service address.
- Do Not submit documentation containing recipient information with your application (e.g., paper claims forms, recipient insurance verification documents, etc.).
Additional Instructions for the Enrollment Form

Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form

Association Types: Enter the letter (B, F, H, I, M, P or U) which best corresponds to the individual's role. Note: ALL lifestyle coaches providing NDPP services for your organization must be listed in Section 5 of the application as a I-Employee/Lifestyle Coach
B: Board of Directors Member F: Facility Administrator H: Compliance Officer I: Employee/Lifestyle Coach
M: Managing Employee P: Supervising Pharmacist U: Laboratory Director
Requirements & Additional Forms
- 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, reinstatement, or reactivation). 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 here.
- Group Member Affiliation/Disaffiliation Request - form #610202 (Each Member MUST complete this form). NOT REQUIRED if you are enrolling as a Managed Care Only non-billing provider)
- 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. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
- 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
- For Changes of Ownership ONLY Provide proof that a Change of Ownership has occurred. Examples of proof include but are not limited to a Bill of Sale, Transfer of Ownership, Operating Agreement, Stock Purchase Agreement, etc.
- 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 or Operating Certificate issued by the NYS Department of Health
- Medicare Enrollment is Required
- 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.
- Proof of current registration with the NYS Education Department For private practicing groups located in New York and established as PC's, LLC's, LLP's or PLLC's: Proof of current registration with the NYS Education Department. (Note: this is not the Department of State). If your copy of the registration is not available, visit http://www.op.nysed.gov/opsearches.htm#.eng, Use the "Search for Professional Business Entity, by Name:" search feature, print your "Business Entity Information" summary and submit it with your Medicaid enrollment form
Provider Compliance Certification - Certification of a Provider Compliance Program may be required. By signing the CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID, you (or the entity) certify that, where required, you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider Compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
Maintenance Forms
- Change of Address - form #610101 Complete on the PE Portal
- Change of Address - form #610601
- Disclosure Form for Businesses - form #380101
- Disclosure Form for Groups - form #380102
- Disclosure Form for Institutions - form #380103
- Disclosure Form for Practitioners - form #380104 Complete on the PE Portal
- EFT Attestation Form - form #701102 Complete on the PE Portal
- Group Member Affiliation/Disaffiliation Request - form #610202 (Each Member MUST complete this form). NOT REQUIRED if you are enrolling as a Managed Care Only non-billing provider)
- Ordering/Prescribing/Referring/Attending FAQs
- Prior Conduct Questionnaire - form #431001 Complete on the PE Portal
  If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
- Status Change Form for Groups - form #426402
- Default Electronic Transmitter Identification Number (ETIN) Selection - form #401103 Complete on the PE Portal
- Provider ID Request Form - form #610801 Complete on the PE Portal
- Request to Disaffiliate/Delete an ETIN - form #401102 Complete on the PE Portal
- Taxpayer Information Update - form #610501 Complete on the PE Portal
Mailing Instructions
1. Keep a copy of all documents submitted, as requests for copies will not be honored.
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

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

Last Updated: 4/2024

Supplemental Information

B: Board of Directors Member		F: Facility Administrator		H: Compliance Officer		I: Employee/Lifestyle Coach
M: Managing Employee		P: Supervising Pharmacist		U: Laboratory Director