ENROLLMENT FORM

Category(s) of Service: 0462

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

  Application Fee is NOT Required  

Provider Index > Physician Assistant > Order/Prescribe/Refer/Attend

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

Orderer-Prescribers-Referrers-Attending 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.
• 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.

  
  

  If the applicant/provider (practitioner) in the Provider Type(s) below is contracted with a Managed Care Plan, they are required to enroll with NYS Medicaid per Section 5005(b)(2) of the 21st Century Cures Act which amended Section1932(d) of the Social Security Act (SSA).

  
  **Leave the following field blank if it does not pertain to you:
      » Specialty
  
  Service Address: Do NOT indicate a Patient's Address. PO Box is NOT Acceptable.
  
  **Ownership in Applicant: If, after you have reviewed 18NYCRR, Section 504.1(d)(18)(iv), you determine this part of Section 1 does not pertain to you, write N/A in the box labeled, "Name of Individual or Entity"
  
  **Section 2, 3 or 4: If one or more of these Sections do not pertain to you, write N/A in the Name box as appropriate.
  
  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
  • 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.

  • Office Based Surgery Program - form #432501    To apply for Office Based Surgery, complete this form
  • 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).
  • Supervising Physician Certification - form #412601   

  
  

  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
  • Affiliation/Disaffiliation Request - form #610201   
  • Change of Address - form #610101   
  • DEA Update - form #610301   
  • Disclosure Form for Practitioners - form #380104   
  • Office Based Surgery Program - form #432501    To apply for Office Based Surgery, complete this form
  • Ordering/Prescribing/Referring/Attending FAQs   
  • 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).
  • Supervising Physician Certification - form #412601   
• 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.