ENROLLMENT FORM

Category(s) of Service: 0140

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

  Application Fee is REQUIRED. Click here for more information.  

Provider Index > Portable X-Ray > Freestanding

Provider Enrollment & Maintenance

Freestanding
Services provided to QMB's only (Qualified Medicare Beneficiaries). This service is NOT available to all Medicaid beneficiaries or individuals with Medicare Part B.

NOTE: To provide services to beneficiaries with NYS Medicaid coverage only, complete Options 1 and 2.


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.
• 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
  • Check Managed Care Only (Non Billing) - If the applicant/provider is contracted with a Managed Care and is required to enroll with NYS Medicaid per the 21st Century Cures Act.

  
  Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form     0140
  
  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
  • 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: Reimbursement is only available for services rendered to Qualified Medicare Beneficiaries (QMB's). For information on who is considered a QMB, visit the Chiropractor and Portable X-Ray Manual at www.emedny.org.

  
  DBA Name: If appropriate
  
  DEA Number & Dates: Leave Blank
  
  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
  • Application Fee
  • A Site Visit     It can be waived if 1) a site visit was conducted by Medicare or another state’s Medicaid or CHIP Programs within the past 12 months; OR 2) your State’s licensing agency has completed a site survey within the past 12 months. Please submit proof with your enrollment form if an eligible site visit has occurred
  • Copy of Your Supervising Physician License    
  • 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    

  • Application Fee Exemption - form #520101   
  • Electronic Funds Transfer (EFT) Authorization - form #701101    (NOT REQUIRED for revalidation if EFT is already in place and no change is requested or if you are enrolling as a Managed Care Only non-billing provider)
  • ETIN Certification Statement for New Enrollments - form #490602    (NOT REQUIRED for revalidation or 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 on eMedny.org under "Maintenance Forms"
  • 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).

  
  

  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.
• Maintenance Forms
  • Change of Address - form #610101   
  • Disclosure Form for Businesses - form #380101   
  • EFT Attestation Form - form #701102   
  • 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).
  • Status Change Form for Businesses - form #436703   
• 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.