NY Medicaid  
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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  


Print Instructions

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


Click Here for New Guidance on Medically Fragile Children Program

Last Updated: 9/2020


Supplemental Information

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.