ENROLLMENT FORM

Category(s) of Service:
0441 - Freestanding - Pharmacy only, OR
0442 - Freestanding - Pharmacy-based DME
* Pharmacy-based DME (0442) can only be enrolled with a Pharmacy (0441). Pharmacy 0441 can enroll without the Pharmacy DME (0442).

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

  Application Fee is REQUIRED. Click here for more information.  

Provider Index > Pharmacy > Freestanding

Provider Enrollment & Maintenance

Freestanding
Prior to completing the Enrollment Form, determine if your pharmacy meets basic criteria for enrollment by using the Pharmacy Primary Screening Form. This form must be included with all other forms for consideration for your enrollment.


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

• General Instructions for the Enrollment Form
  • 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.
  • Do Not submit documentation containing recipient information with your application (e.g., paper claims forms, recipient insurance verification documents, etc.
• Additional Instructions for the Enrollment Form
  Choose only ONE of the following options & check the corresponding box on the top of the Enrollment Form

  • Check Billing Provider - If the applicant/provider intends on Billing NYS Medicaid

  
  Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form     
  0441 - Freestanding - Pharmacy only, OR
  0442 - Freestanding - Pharmacy-based DME
  * Pharmacy-based DME (0442) can only be enrolled with a Pharmacy (0441). Pharmacy 0441 can enroll without the Pharmacy DME (0442).
  
  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 Change of Ownership to comply with 42 CFR, Part 455.104 - Proof that a Change of Ownership has occurred is required. See Requirements and Additional Forms (below).
  • 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.

  
  DBA Name: If appropriate
  
  NPI:this field is required. NPI must be registered to the pharmacy and active at https://npiregistry.cms.hhs.gov. Only 1 NPI per service location is allowed.
  
  DEA Number & Dates: Required
  
  Medicare enrollment is required prior to applying for Medicaid enrollment:
  If the pharmacy is applying for or enrolled in Medicaid category of service 0441, Medicare enrollment is required. Please compete the Attestation of Need for/Exemption from Medicare Enrollment form and submit with your application. To enroll in Medicare, visit: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Enrollment-Applications. Do not submit Medicare enrollment forms with your NYS application.
  
  Service Address: This address must match the address on your pharmacy license/registration
  
  Supervising Pharmacist: This field is required. Enrollment in the New York Medicaid program is required for a supervising pharmacist when employed by a freestanding pharmacy. If supervising pharmacist is not enrolled or in an inactive status, submission of a practitioner enrollment is required along with supplemental documentation for the 0444 Category of service at https://www.emedny.org/info/ProviderEnrollment/spharm/index.aspx
  
  Association Types: Enter the letter (B, F, H, I, M, P or U) which best corresponds to the individual's role:    Note: ALL lifestyle coaches providing NDPP services for your organization must be listed in Section 5 of the application as a I-Employee/Lifestyle Coach

  B: Board of Directors Member		F: Facility Administrator		H: Compliance Officer		I: Employee/Lifestyle Coach
  M: Managing Employee		P: Supervising Pharmacist		U: Laboratory Director

• Requirements & Additional Forms
  • Application Fee ($688)
    Medicare enrollment is required for Pharmacy enrollment in Medicaid. If the pharmacy is enrolled with Medicare, please complete the Application Fee Exemption - form #520101, as you will not be required to pay an additional fee to Medicaid.
  • Application Fee Exemption - form #520101   
  • Attestation of Need for/Exemption from Medicare Enrollment - form #409602    Completion is required. Failure to complete this form will cause your application to be rejected and returned.
  • DEA Form - form #610301    Completion is required, failure to complete this form may cause your application to be rejected and returned.
  • Electronic Funds Transfer (EFT) Authorization - form #701101    (NOT REQUIRED for revalidation if EFT is already in place and no change is requested)
  • ETIN Certification Statement for New Enrollments - form #490602    (NOT REQUIRED for revalidation, reinstatement, reactivation, or if you are enrolling as a Managed Care Only non-billing provider). If you already have an existing ETIN that you wish to affiliate with, submit the Certification Statement for Existing ETINs (EMEDNY 490601) after you receive your Provider ID. This form is available here.
  • Hospital, Nursing Home, Clinic Based Pharmacy Questionnaire - form #409010   
  • Out of State Pharmacy Application - form #402101   
  • Personal Identification Number (PIN) Request - form #409601   
  • Pharmacy Information Request - form #409501    Be sure to include additional documentation requested on this form
  • Pharmacy Primary Screening - form #409502    Prior to completing the Enrollment Form, determine if your pharmacy meets basic criteria for enrollment by using the Pharmacy Primary Screening Form. This form must be included with all other forms for consideration for your enrollment, revalidation, or reinstatement.
  • Prior Conduct Questionnaire - form #431001    If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
  • Supervising Pharmacist Agreement - form #409901    (for your Medicaid-enrolled Supervising Pharmacist)
  • DEA Certificate     Copy of your DEA certificate or web based printout from the office of Diversion Control website at https://www.deadiversion.usdoj.gov/webforms/dupeCertLogin.jsp. Note: Completion of the DEA Form 610301, is also required.
  • For Changes of Ownership ONLY     Provide proof that a Change of Ownership has occurred. Examples of proof include but are not limited to a Bill of Sale, Transfer of Ownership, Operating Agreement, Stock Purchase Agreement, etc.
  • For out of State Pharmacies Only:    

    1,    Complete Form 402101, and

    2.     DMEPOS Competitive Bid/Contract Suppliers should include Proof of Contract Supplier Status

  • IRS Assignment Letter indicating the FEIN and Applicant Name on the Enrollment Form     (W-9 NOT ACCEPTABLE). IRS Assignment Letter (Form: SS-4) can be obtained by going to IRS.Gov or call IRS at 1-800-829-4933
  • Medicare Enrollment is Required    
  • Medicare enrollment is required prior to applying for Medicaid enrollment:     If the pharmacy is applying for or enrolled in Medicaid category of service 0441, Medicare enrollment is required. Please compete the Attestation of Need for/Exemption from Medicare Enrollment form and submit with your application. To enroll in Medicare, visit: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Enrollment-Applications. Do not submit Medicare enrollment forms with your NYS application.
  • New York State Board of Pharmacy Certificate    

  
  

  Provider Compliance Certification - Certification of a Provider Compliance Program may be required. By signing the CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID, you (or the entity) certify that, where required, you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider Compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
• Maintenance Forms
  • Attestation of Need for/Exemption from Medicare Enrollment - form #409602    Completion is required. Failure to complete this form will cause your application to be rejected and returned.
  • Change of Address - form #610101   
  • DEA Form - form #610301    Completion is required, failure to complete this form may cause your application to be rejected and returned.
  • Disclosure Form for Businesses - form #380101   
  • EFT Attestation Form - form #701102   
  • Personal Identification Number (PIN) Request - form #409601   
  • Prior Conduct Questionnaire - form #431001    If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
  • Status Change Form for Businesses - form #436703    This form is to be used when a pharmacy wishes to voluntarily terminate their New York State Medicaid enrollment
  • Supervising Pharmacist Agreement - form #409901    (for your Medicaid-enrolled Supervising Pharmacist)
• Mailing Instructions
  1. Keep a copy of all documents submitted
  2. Send the completed enrollment form, required documents and additional forms to:

  STANDARD MAILING	EXPEDITED / PRIORITY MAILING
  eMedNY P.O. Box 4603 Rensselaer, NY 12144-4603	eMedNY ATTN: Box 4603 327 Columbia Turnpike Rensselaer, NY 12144

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.