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
Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form 0621 - Occupational Therapy, OR 0622 - Physical Therapy, OR 0623 - Speech Pathology
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 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.
DEA: Leave Blank
Type of Practice: For each service address, check the box from the list which best describes your type of practice at that address.
Place of Service For each service address, check the box from the list which best describes the site.
Association Types: Enter the letter (B, F, H, I, M, P or U) which best corresponds to the individual's role: Note: ALL lifestyle coaches providing NDPP services for your organization must be listed in Section 5 of the application as a I-Employee/Lifestyle Coach
B: Board of Directors Member
F: Facility Administrator
H: Compliance Officer
I: Employee/Lifestyle Coach
M: Managing Employee
P: Supervising Pharmacist
U: Laboratory Director
Requirements & Additional Forms
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
Medicare Enrollment is Required for Physicial Therapists Only
Proof of current license / registration Examples: 1) Copy of license with future expiration date, 2) Copy of license registration/renewal, or 3) Printout of your license status from the licensing agency’s website.
Electronic Funds Transfer (EFT) Authorization - form #701101 (NOT REQUIRED for revalidation if EFT is already in place and no change is requested). If you answered "No" to the Enrollment Form's Group question (Line 4 of page 2), EMEDNY
-701101 is NOT required. Also not required for revalidation or reinstatement/reactivation
ETIN Certification Statement for New Enrollments - form #490602 (NOT REQUIRED for revalidation or reinstatement/reactivation). 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"
Provider Compliance Certification - Certification of a Provider Compliance Program MAY BE required. By signing the CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID, you (or the entity) certify that, where required, you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider Compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
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