ENROLLMENT FORM

Category(s) of Service: 0469

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

  Application Fee is NOT Required  



Print Instructions

Provider Index > Nurse Practitioner > Order/Prescribe/Refer/Attend

Provider Enrollment & Maintenance



Special Note for Attending Nurse Practitioners:
Attending Nurse Practitioners should complete the form below if their name/NPI will ONLY be found on a claim submitted by the Hospital. If the practitioner will be attesting for MEIPASS/EHR Incentive, do not apply as an OPRA provider.


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

Orderer-Prescribers-Referrers-Attending Enrollment Form

Last Updated: 8/2017


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.