NY Medicaid  
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ENROLLMENT FORM

Category(s) of Service:
0046 - Group is comprised of Physicians Only, OR Physicians and/or Nurse Practitioners and/or Physician Assistants , OR
0090 - Group is comprised of various Licensed Professionals

(e.g., physicians, nurse practitioners, registered physician assistants, clinical psychologists, podiatrists, chiropractors, clinical social workers, optometrists, therapists (physical, occupational, speech), Midwives, Licensed Marriage and Family Therapists, License Mental Health Counselors, Licensed Behavior Analysts (LBA), Certified Behavior Analyst Assistants (CBAA))

If your group contains ONLY opticians and/or optometrists, an Optical Establishment application should be completed. Do not complete a group application.



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

  Application Fee is NOT Required  


Print Instructions

Provider Index > Practitioner Groups

Provider Enrollment & Maintenance



Multi Professional Group Providers: Group is comprised of various Licensed Professionals (e.g., physicians, nurse practitioners, registered physician assistants, clinical psychologists, podiatrists, chiropractors, clinical social workers, optometrists, therapists (physical, occupational, speech), Midwives, Licensed Marriage and Family Therapists, License Mental Health Counselors, Licensed Behavior Analysts (LBA), Certified Behavior Analyst Assistants (CBAA))

Physician Group Providers: Group is comprised of Physicians Only, OR Physicians and/or Nurse Practitioners and/or Physician Assistants




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

GROUP Enrollment Form

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email. Please note, the Medicaid Pending Provider Listing lists all applications that are in process, and the Medicaid Enrolled Provider Listing lists all enrollments that have been approved.
Last Updated: 6/2024


Supplemental Information

033-10:52:41 PM