ENROLLMENT FORM

Category(s) of Service: 0268

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

  Application Fee is REQUIRED. Click here for more information.  


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Provider Index > OMH Licensed PROS Provider

Provider Enrollment & Maintenance



OMH Licensed PROS Provider:
PROS is a comprehensive recovery oriented program for individuals with severe and persistent mental illness. The goal is to integrate treatment, support and rehabilitation to facilitate recovery.


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, or
  5. Reporting a RECEIVERSHIP

INSTITUTION Enrollment Form

Last Updated: 9/2017


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.