Provider Enrollment > Provider Maintenance Forms

Provider Maintenance Forms

PLEASE TAKE NOTE: We recently removed many of the maintenance forms from this page. Links to forms such as Change of Address and Request to Participate as a Group Member are now accessed on the Provider Enrollment page by clicking on your provider type.

All forms and packets are typeable.
This enhancement alleviates problems related to legibility of the information entered on the forms.

Please open and type your information into the form, then print, sign and mail in to eMedNY.
Please use the tab key or the mouse to move from field to field on typeable forms.

Miscellaneous Maintenance Forms	= Available on the Provider Enrollment Portal

Certification Statement/Instructions for Existing ETINs Default Electronic Transmitter Identification Number (ETIN) Selection Form CLICK HERE to Complete this form on the new Provider Enrollment Portal Note: Available for Practitioners Only Electronic Funds Transfer (EFT) Authorization Form CLICK HERE to Complete this form on the new Provider Enrollment Portal Note: Available for Practitioners Only NOTE: Instead of filling out the EFT Authorization Form above, you can complete the form online at: https://portal.emedny.org/provider/ Electronic Prior Approval Request Form Electronic or PDF Remittance Advice Request NOTE: Instead of filling out the Electronic or PDF Remittance Advice Request Form above, you can complete the form online at: https://portal.emedny.org/provider/ Paper Remittance Sort Request Form	Pended Claim Recycle Request Form Prior Approval Roster Request Form Provider Electronic/Paper Transmitter Identification Number (ETIN) Provider ID Request Form CLICK HERE to Complete this form on the new Provider Enrollment Portal Note: Available for Practitioners Only Remittance Consent and Copy Request Forms Request For Provider Reports Request to Disaffiliate/Delete an ETIN CLICK HERE to Complete this form on the new Provider Enrollment Portal Note: Available for Practitioners Only Service Bureau Electronic/Paper Transmitter Identification Number (ETIN) Tax Update Form CLICK HERE to Complete this form on the new Provider Enrollment Portal Note: Available for Practitioners Only Trading Partner Agreement