Category(s) of Service: 0469

If you are ALREADY ENROLLED and need to change your address,

click here.

Application Fee is NOT Required

Provider Index > Nurse Practitioner > Order/Prescribe/Refer/Attend

Provider Enrollment & Maintenance

Complete this Enrollment Form if you are:

Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
Responding to a letter instructing you to REVALIDATE your enrollment, or
Seeking REINSTATEMENT or REACTIVATION of your previous enrollment

Orderer-Prescribers-Referrers-Attending Enrollment Form

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email. Please note, the Medicaid Pending Provider Listing lists all applications that are in process, and the Medicaid Enrolled Provider Listing lists all enrollments that have been approved.

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
Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form 0469
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.
**Leave the following field blank if it does not pertain to you:
» Specialty

Service Address: Do NOT indicate a Patient's Address. PO Box is NOT Acceptable.

**Ownership in Applicant: If, after you have reviewed 18NYCRR, Section 504.1(d)(18)(iv), you determine this part of Section 1 does not pertain to you, write N/A in the box labeled, "Name of Individual or Entity"

**Section 2, 3 or 4: If one or more of these Sections do not pertain to you, write N/A in the Name box as appropriate.

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
- Application as a Specialist - form #490301 if applicable
- Collaborating Physician Form - form #410501 (only required if the applicant has fewer than 3,600 hours of qualifying nurse practitioner practice)
- DEA Form - form #610301 Completion is required, failure to complete this form may cause your application to be rejected and returned.Additional Instructions for form completion:
  If you are licensed to and DO prescribe, administer, or dispense controlled substances, you are required to complete only Sections A and C.
  If you are licensed to but do NOT prescribe, administer, or dispense controlled substances, you are only required to complete only Sections A and B.
  Note for practitioners: If employed by an institution and authorized to use the Institution's DEA, submit a copy of that DEA and proof of the suffix/identifier assigned to you by the Institution.
- MOMS Application Addendum - form #405201
- MOMS Info For Providers - form #405101 To apply for Medicaid Obstetrical and Maternal Services (MOMS) complete this form.
- Physician Office Lab - CLIA Information - form #408501 To apply for Physician Office Laboratory-CLIA, complete this form
- PPAC Nurse Practitioner Application - form #411201 To apply for the Preferred Physicians and Children Program (PPAC),complete this form and return it with the Enrollment Form
- PPAC Nurse Practitioner Instructions - form #411101
- 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.
- DEA Certificate
  If you do NOT prescribe, administer, or dispense controlled substances, then you do NOT need to submit a DEA certificate. You must, however, complete and submit the DEA Form (EMEDNY #610301) found below.
  
  If you DO prescribe, administer, or dispense controlled substances, then you must submit a copy of your DEA certificate or a web-based printout from the Office of diversion Control website at https://www.deadiversion.usdoj.gov/webforms/dupeCertLogin.jsp and complete the DEA Form (EMEDNY #610301). If employed by an institution and authorized to use the institution’s DEA, you must submit a copy of the institution’s DEA certificate and proof of the suffix/identifier assigned to you by the institution.
- Proof of current license / registration Examples: 1) Copy of license with future expiration date, 2) Copy of license registration/renewal, or 3) Printout of your license status from the licensing agency’s website.
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
- Affiliation/Disaffiliation Request - form #610201 Complete on the PE Portal
- Application as a Specialist - form #490301 Complete on the PE Portal
  if applicable
- Change of Address - form #610101 Complete on the PE Portal
- Collaborating Physician Form - form #410501 (only required if the applicant has fewer than 3,600 hours of qualifying nurse practitioner practice)
- DEA Form - form #610301 Complete on the PE Portal
  Completion is required, failure to complete this form may cause your application to be rejected and returned.Additional Instructions for form completion:
  If you are licensed to and DO prescribe, administer, or dispense controlled substances, you are required to complete only Sections A and C.
  If you are licensed to but do NOT prescribe, administer, or dispense controlled substances, you are only required to complete only Sections A and B.
  Note for practitioners: If employed by an institution and authorized to use the Institution's DEA, submit a copy of that DEA and proof of the suffix/identifier assigned to you by the Institution.
- Disclosure Form for Practitioners - form #380104 Complete on the PE Portal
- MOMS Application Addendum - form #405201 Complete on the PE Portal
- MOMS Info For Providers - form #405101 Complete on the PE Portal
  To apply for Medicaid Obstetrical and Maternal Services (MOMS) complete this form.
- Ordering/Prescribing/Referring/Attending FAQs
- Physician Office Lab - CLIA Information - form #408501 Complete on the PE Portal
  To apply for Physician Office Laboratory-CLIA, complete this form
- PPAC Nurse Practitioner Application - form #411201 Complete on the PE Portal
  To apply for the Preferred Physicians and Children Program (PPAC),complete this form and return it with the Enrollment Form
- PPAC Nurse Practitioner Instructions - form #411101 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.
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

STANDARD MAILING	EXPEDITED / PRIORITY MAILING
eMedNY P.O. Box 4603 Rensselaer, NY 12144-4603	eMedNY ATTN: Box 4603 327 Columbia Turnpike Rensselaer, NY 12144

Last Updated: 6/2023

Supplemental Information

Nurse Practitioner Manual

B: Board of Directors Member		F: Facility Administrator		H: Compliance Officer		I: Employee/Lifestyle Coach
M: Managing Employee		P: Supervising Pharmacist		U: Laboratory Director