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.
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
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.
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 ($599 - effective 01/01/2021) 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.
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 if you are licensed to prescribe or dispense controlled substances. If employed by an institution and authorized to use the Institution's DEA, submit a copy of that DEA and proof of the suffix/identifier assigned to you by the Institution
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:
Complete Form 402101, and
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
ETIN Certification Statement for New Enrollments - form #490602 (NOT REQUIRED for revalidation or reinstatement/reactivation.) 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 on eMedny.org under "Maintenance Forms."
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.
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