ENROLLMENT FORM

Category(s) of Service:
0602 - Ambulette /Invalid Coach - non-medical (IMPORTANT: Medicaid ambulette providers will be denied enrollment in the Medicaid program when the proposed service will operate in New York City (five boroughs), and/or Nassau and/or Suffolk County. Please review current policy located on Page 22 of the Transportation Manual ), 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.  


Print Instructions

Provider Index > Transportation > Non Medical

Provider Enrollment & Maintenance


Non Medical

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

BUSINESS Enrollment Form

Last Updated: 3/2019


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.