ENROLLMENT FORM

Doula Enrollment Instructions

To update information for the NYS Medicaid Fee-for-Service Doula Directory, click here.

Category(s) of Service: 0464

  Application Fee is NOT Required  

Provider Index > Doula (Perinatal) > Billing Medicaid

Provider Enrollment & Maintenance

Billing Medicaid

PRACTITIONER Enrollment Form

• 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

  For step-by-step guidance on completing the enrollment form, please view Doula Sample Practitioner Enrollment Form.

  
  Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form     0464
  
  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 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.

  
  NPI: This field is required.
  
  DEA Number & Dates: N/A
  
  License: Leave Blank.
  
  Type of Practice: In the service address field Check the box, Individual (1) from the list.
  
  Place of Service: Enter your office or home address (if NO primary office available) per DOH Policy, then check the box which best describes the site (If applicable).
  
  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
  Instructional Forms

  • Doula Enrollment Instructions
  • Doula Sample Practitioner Enrollment Form
  • Visualization of Enrollment Pathways

  
  Required Forms

  • Doula Client and Professional Recommendation Forms - form #433403    for Work Experience Pathway only.
  • Doula Attestation Form - form #433402    Required for all Doula applicants: Work Experience Pathway and Training Pathway applicants
  • Electronic Funds Transfer (EFT) Authorization - form #701101   
    - For newly enrolling providers, disregard mailing address on form and, instead, submit with enrollment form and supporting documents.
    - Form is not required if submitting a revalidation or reinstatement/reactivation and no changes to the EFT are being requested.
    - Form is not required if you are affiliated with a group and DO NOT have a private practice.
  • 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.
  • Training Pathway Only    

    A Copy of the Doula Training Certificate or if the doula training organization that provided doula training does not provide a certificate of completion, a signed and dated letter on the doula training organization's letterhead stating the doula has completed a doula training course can be substituted for a certificate.

    Additional copies of doula training to meet core and broader competencies, as applicable.

  • Work Experience Pathway Only    

    A total of three completed Client and/or Professional Recommendation Forms - form #433403

  
  

  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    Complete on the PE Portal
    
  • Disclosure Form for Practitioners - form #380104    Complete on the PE Portal
    
  • EFT Attestation Form - form #701102    Complete on the PE Portal
    
  • Prior Conduct Questionnaire - form #431001    Complete on the PE Portal
    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.

  • Additional forms related to revalidation will be forthcoming
• 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