Financial Information

This page lists forms pertaining to requesting or updating specific financial information. Please check back here as new forms will appear.

Online Forms

Request for Financial Reports
This form may be used by enrolled providers to request information on their NY Medicaid financial file.

Request for Payoff Balance
This form may be used by enrolled providers to initiate the process of paying off an outstanding liability.

Paper Forms

ETIN Name and Address Change

Payment Listing Form

1099 Duplicate Request Form

Copy of Cleared Check Form

Stop and Reissue Request Form

Pay-To-Group Only Qualifier Removal Request Form

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This website is provided as a service for providers and the general public, as part of the offerings of the electronic Medicaid system of New York State. You'll be able to find helpful manuals and reference material, and get answers to questions about New York Medicaid. The site is updated regularly to meet the ever-growing needs of the New York State provider community. If you need help finding what you're looking for, please visit our Site Map, use the search above, or you can contact us directly for assistance.

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