NY Medicaid  
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Category(s) of Service: 0460

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

  Application Fee is NOT Required  

Print Instructions

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

Provider Enrollment & Maintenance

Special Note for Attending Physicians:
Attending Physicians should complete the form below if their name/NPI will ONLY be found on a claim submitted by the Hospital. If the practitioner will be attesting for MEIPASS/EHR Incentive, do not apply as an OPRA provider.

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

Last Updated: 9/2022

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.

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