NY Medicaid  
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Request for Payoff Balance

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

For general balance inquiries, please refer to your current Medicaid Remittance Statement or contact the eMedNY call center at 1-800-343-9000.

Provider Name:
Requestor Name: (your name)
Requestor Email:
Select one of the following:


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