ENROLLMENT FORM

Category(s) of Service:
0401 - with Salaried Optometrist/Salaried Optician (must have at least one Optometrist), AND/OR
0402 - with Salaried Opticians - No Optometrists


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 > Optical Establishment

Provider Enrollment & Maintenance



The New York State Department of Health and the Department of Correctional Services (DOCS) have jointly implemented a program to provide eyeglass materials to Medicaid recipients whose county of fiscal responsibility is a county other than New York City. Under this program, if you become enrolled in the Medicaid Program as an eyeglass dispenser (i.e., optometrist, optician, or retail optical establishment) you would forward eyeglass prescriptions for Medicaid recipients to the DOCS/DOH Project so that the materials can be produced by DOCS at their Wallkill facility in Ulster County. The completed eyeglasses will be returned directly to you. Dispensing providers will continue to bill the Medicaid Program for their other professional services, i.e., examinations and dispensing fees. If you service recipients from counties other than New York City, youshould contact DOCS at (800) 836-2636 to receive an information package, sample frame kit and order forms.


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, or
  4. Reporting an OWNERSHIP CHANGE

BUSINESS Enrollment Form

Last Updated: 7/2018


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.