Provider Index > Portable X-Ray > Freestanding
Provider Enrollment & Maintenance
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:
- Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
- Responding to a letter instructing you to REVALIDATE your enrollment, or
- Seeking REINSTATEMENT or REACTIVATION of your previous enrollment, or
- Reporting an OWNERSHIP CHANGE
BUSINESS Enrollment Form