NY Medicaid  
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ENROLLMENT FORM

Category(s) of Service: 0631

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

  Application Fee is NOT Required  


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Provider Index > Medicare Cost Sharing Practitioner

Provider Enrollment & Maintenance



This restricted category of service is only for Medicare-enrolled individual practitioners who intend to enroll in Medicaid for the sole purpose of submitting claims for cost-sharing for services rendered to dually enrolled Medicare/Medicaid members, thus enabling receipt of a zero-payment remittance advice from Medicaid.


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

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.
Last Updated: 2/2024


Supplemental Information
    None at this time


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