ENROLLMENT FORM

Category(s) of Service:
0521 - Licensed Practical Nurse, OR
0522 - Registered Nurse

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

  Application Fee is NOT Required  

Provider Index > Nurse (LPN/RN) > 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

• 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.
  • Valid Telephone numbers are required for each service address.
• Additional Instructions for the Enrollment Form
  
  Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form     
  0521 - Licensed Practical Nurse, OR
  0522 - Registered Nurse
  
  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 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.

  
  DEA Number & Dates: Leave Blank
  
  Service Address: Enter your home address
  
  Type of Practice: Leave Blank
  
  Place of Service: Leave Blank
  
  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
  • 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.

  • Electronic Funds Transfer (EFT) Authorization - form #701101    (NOT REQUIRED for revalidation if EFT is already in place and no change is requested). If you answered "No" to the Enrollment Form's Group question (Line 4 of page 2), EMEDNY -701101 is NOT required. Also not required for revalidation or reinstatement/reactivation
  • ETIN Certification Statement for New Enrollments - form #490602    (NOT REQUIRED for revalidation or reinstatement/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 on eMedny.org under "Maintenance Forms"
  • Medically Fragile Children Program - form #432301    To apply for the Medically Fragile Children PDN Enhancement, complete this form
  • 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 #610101   
  • Disclosure Form for Practitioners - form #380104   
  • EFT Attestation Form - form #701102   
  • Medically Fragile Children Program - form #432301    To apply for the Medically Fragile Children PDN Enhancement, complete this form
  • 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.