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.
Additional Instructions for the Enrollment Form
Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form 0462
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 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.
REMINDER Physician Assistant is a non-reimbursable category of service. Services are paid to your Supervising Physician who must be enrolled in the NYS Medicaid Program and will be at financial risk if you render service to Medicaid patients before successfully completing the enrollment process. Payment will not be made for any claims submitted for service, care or supplies furnished before your enrollment date is authorized by Medicaid.
DEA Number & Dates: Complete if you are licensed to prescribe or dispense controlled substances
Type of Practice: For each service address, check the box from the list which best describes your type of practice at that address.
Place of Service For each service address, check the box from the list which best describes the site.
Group/Organization: If your Supervising Physician is a member of a group currently enrolled in the NYS Medicaid Program, enter the Group/Organization Name and NPI.
Association Types: Enter the letter (B, F, H, M, P or U) which best corresponds to the individual's role:
B: Board of Directors Member
F: Facility Administrator
H: Compliance Officer
M: Managing Employee
P: Supervising Pharmacist
U: Laboratory Director
Requirements & Additional Forms
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
Proof of current license / registration Examples: 1) Copy of license with future expiration date, 2) Copy of license registration/renewal, or 3) Printout of your license status from the licensing agency’s website.
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"
OMIG Provider Compliance Certification - Confirmation notice for the OMIG Provider Compliance Program may be required. Visit www.omig.ny.gov to determine if the Applicant / Provider must comply. If yes, a copy of the confirmation notice (printed from the website) must be included with this application.
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