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.
If the applicant/provider (practitioner) in the Provider Type(s) below is contracted with a Managed Care Plan, they are required to enroll with NYS Medicaid per Section 5005(b)(2) of the 21st Century Cures Act which amended Section1932(d) of the Social Security Act (SSA).
**Leave the following field blank if it does not pertain to you: » Specialty
Service Address: Do NOT indicate a Patient's Address. PO Box is NOT Acceptable.
**Ownership in Applicant: If, after you have reviewed 18NYCRR, Section 504.1(d)(18)(iv), you determine this part of Section 1 does not pertain to you, write N/A in the box labeled, "Name of Individual or Entity"
**Section 2, 3 or 4: If one or more of these Sections do not pertain to you, write N/A in the Name box as appropriate.
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.
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.
ENROLLMENT FORM
click here.
Orderer-Prescribers-Referrers-Attending Enrollment Form