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eMedNY Paper Forms

Please note that these sample forms are intended to provide you with advanced planning information. These samples are not to be used for live submission of information to NY Medicaid.

Paper submission of claims and requests to New York Medicaid must be presented on original forms.



Claim Forms   USERS
 

Claim Form A

eMedNY 150003

Pharmacy Claim Form

NUBC UB-04

Dental, Transportation

Fee for Service

Pharmacy

Rate Based

 
Prior Authorization Forms
 
 
Electronic Attachment Scanning Form and
Instructions
 
 
Medicaid Utilization Threshold Program
 
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