ENROLLMENT FORM

Category(s) of Service:
0403 - Optician - Salaried, OR
0404 - Optician - Self-Employed


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

  Application Fee is REQUIRED. Click here for more information.  


Print Instructions

Provider Index > Optician/Opthalmic Dispenser (OPD) > 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

Last Updated: 3/2015


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.