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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


Dental, Transportation

Fee for Service


Rate Based

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