Category(s) of Service:
0602 - Ambulette /Invalid Coach - non-medical , OR
0603 - Taxi (Upstate Taxi only), OR
0605 - Livery / Black Car (NYC only), OR
0606 - OPWDD Transport, OR
0609 - Transportation Network Company/High Volume for Hire Services

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

click here.

Application Fee is REQUIRED. Click here for more information.

Provider Index > Transportation > Non Medical

Provider Enrollment & Maintenance

Non Medical

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

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.

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 be valid on the application date and continuously valid through the current date.
- An original signature is required. 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, as requests for copies cannot be honored.
- Valid telephone numbers are required for each service address.
- Do Not submit documentation containing recipient information with your application (e.g., paper claims forms, recipient insurance verification documents, etc.).
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
0602 - Ambulette /Invalid Coach - non-medical , OR
Under current Medicaid guidelines, potential Medicaid ambulette providers are denied enrollment in the Medicaid program when the proposed service will operate in New York City, and/or Nassau and/or Suffolk County as it has been determined by the New York State Department of Health that these locations have an adequate number of existing ambulette providers.

IMPORTANT: The moratorium will lift 12/01/2021. This supersedes the previous guidance and allows ambulette companies to enroll in Category of Service 0602 across all counties (contingent on the provider meeting other enrollment criteria). Previously denied applications will not be automatically processed. If an ambulette provider submitted an application prior to December 1, they may reapply starting December 1.

0603 - Taxi (Upstate Taxi only), OR
0605 - Livery / Black Car (NYC only), OR
0606 - OPWDD Transport, OR
0609 - Transportation Network Company/High Volume for Hire Services
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 - Proof that a Change of Ownership has occurred is required. See Requirements and Additional Forms (below).
- 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.
DBA Name: If appropriate

DEA Number & Dates: Leave Blank

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
PLEASE NOTE: Only complete applications containing all requirements and additional forms will be accepted for processing. Applications with missing or incomplete information will be rejected and returned
- Application Fee ($709)
- 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, reinstatement, or 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 here.
- 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. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
- Transportation Information Request - form #424601
- Copy of Your Certificate(s), Registration(s), Permit(s), License(s) as determined by the attached chart CLICK HERE
- For Changes of Ownership ONLY Provide proof that a Change of Ownership has occurred. Examples of proof include but are not limited to a Bill of Sale, Transfer of Ownership, Operating Agreement, Stock Purchase Agreement, etc.
- If located outside of NYS, include a copy of your participation letter with your State's Medicaid Program
- 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
- Letter of Support from Medical Answering Services (MAS) is REQUIRED. For more information related to MAS and this process, please refer to the "Become a Provider" section of the MAS website, found here. Additional questions can be emailed to tprelations@medanswering.com. Any new application submitted after 04/15/2024 without the MAS support letter will be rejected and returned.
- Signed Attestation for Non-Medical Transportation Providers CLICK HERE
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.
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. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
- Status Change Form for Businesses - form #436703
Mailing Instructions
1. Keep a copy of all documents submitted, as requests for copies will not be honored.
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

STANDARD MAILING	EXPEDITED / PRIORITY MAILING
eMedNY P.O. Box 4603 Rensselaer, NY 12144-4603	eMedNY ATTN: Box 4603 327 Columbia Turnpike Rensselaer, NY 12144

Last Updated: 4/2024

Supplemental Information

Attention Non-Medical Transportation Providers:

COS 0602 - Ambulette/Invalid Coach
COS 0603 - Taxi
COS 0605 - Livery/Black Car
COS 0609 - Transportation Network Company

Effective 03/01/2024:

Non-Medical Transportation Providers can no longer enroll as Managed Care (non-billing) providers.
All Non-Medical Transportation applicants are required to submit a Letter of Support from Medical Answering Services (MAS). For more information related to MAS and this process, please refer to the "Become a Provider" section of the MAS website, found here. Additional questions can be emailed to tprelations@medanswering.com. Any new application submitted after 04/15/2024 without the MAS support letter will be rejected and returned.

Note: Successful Medicaid enrollment is not a guarantee of trip assignments. Medicaid trips are assigned by MAS based upon the Medicaid enrollee's expressed choice of network transportation vendors or, where the enrollee expresses no choice, the medical practitioner's choice; and finally, where no choice is expressed, by rotation.

B: Board of Directors Member		F: Facility Administrator		H: Compliance Officer		I: Employee/Lifestyle Coach
M: Managing Employee		P: Supervising Pharmacist		U: Laboratory Director