Emedny 436601 Form PDF Details

Emedny 436601 form is an essential document for any healthcare professional. This form is used to record patient information and track medical history. It is important to understand the purpose of this form and how to complete it accurately. The emedny 436601 form can be used to provide insurance coverage and generate billing statements. Make sure you are familiar with all of the sections on this form before you begin completing it. The emedny 436601 form should be filled out completely and accurately for the best results.

Question	Answer
Form Name	Emedny 436601 Form
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	SSN, NPI, 42CFR, emedny form 436601

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New York State Medicaid

Enrollment Form

Thank you for your interest in enrolling with the New York State Medicaid Program. As a Medicaid provider, you agree to comply with the rules, regulations and official directives of the Department including, but not limited to, Part 504 of 18 NYCRR (i.e., Title 18). Title 18 can be found by choosing the Laws and Regulations link of the Department of Health’s website, www.health.ny.gov.

You will be at financial risk if you render services to Medicaid beneficiaries before successfully completing the enrollment process. Payment will not be made for any claims submitted for services, care, or supplies furnished before the enrollment date authorized by the Department of Health. If you have any questions, contact the eMedNY Call Center at (800) 343-9000.

New York State’s Personal Privacy Protection Law requires us to inform every person from whom we request personal information why we are requesting information and how we will use it. The information requested will permit proper payments to you as a Medicaid provider, according to the provisions of applicable State and Federal Law and Regulations. Collection of this information is authorized by Section 367-b of the Social Services Law. This information will be used as one element of various reviews before payment is made for the goods or services furnished and/or for any post payment audits required by the State or Federal authorities. This information will also be used to satisfy the reporting requirement imposed upon us by State and Federal Regulations (e.g., by IRS for payment information reporting purposes). Failure to provide us with the information will prevent establishing the records necessary to enroll you as a Medicaid provider. The information will be maintained by the New York State Department of Health, Office of Health Insurance Programs, Division of OHIP Operations, Bureau of Provider Enrollment, 150 Broadway, Albany, NY 12204

EMEDNY-436601 (07/12)

NY MEDICAID PROVIDER ENROLLMENT FORM

for

INSTITUTIONS & RATE-BASED PROVIDERS

Mail to:

Computer Sciences Corporation

PO Box 4603

Rensselaer, NY 12144-4603

Category(s) of Service: Enter 4-digit code(s) given in the instructions: _________ _________

New Enrollment

(not currently enrolled)

Revalidation

(enrolled; required to revalidate)

Change of Ownership

(enrolled, complying with 42CFR Part

455.104)

Reinstatement/Reactivation

Receivership

(not currently enrolled)

(enrolled with appointed Receiver)

Enrollment Effective Date (< 90 days ago)

FEIN

NPI

(unless exempt)

(MM/DD/YYYY)

Applicant / Business Name (exactly as it appears

on your license/registration)

NY Medicaid ID (if currently or prev. enrolled)

Doing Business As (DBA) Name

License # Assoc. With this enrollment

NY State Licensing Agency:

01-DOH

02-OMH 03-SED

 05-OASAS

07-OPWDD 99-Out-of-State

License # Assoc. With this enrollment

NY State Licensing Agency:

01-DOH

02-OMH 03-SED

 05-OASAS

07-OPWDD 99-Out-of-State

Fiscal Year Date (MM/DD)

Control of Facility (see instructions)

DEA or NYS Cont. Subs Lic # (if required per instructions)

Effective Date (MM/DD/YYYY)

Expiration Date(MM/DD/YYYY)

Are you enrolled

 Yes

 No

# of Beds (if

required):

Applicant’s e-Mail Address:

in Medicare?

Ownership Code:

69-Federal

70

-County

71-Municipal

72-State

73-Voluntary / Not-for-Profit

74-For Profit Corp.

75-For Profit Partnership 76-For Profit-Individual

 19-Other: Explain ____________

CORRESPONDENCE: (indicate where letters and claims forms, if any, should be sent) – PO Box not acceptable

Attention:

Street Address

Suite / Department / Floor

City

State

Zip Code (9 digits)

County (if in New York)

Telephone Number (w/ extension)

Fax Number

PAY TO ADDRESS: (indicate where checks & remittance statements should be sent until EFT and e-Remits are in place):

Attention:	Street Address or PO Box	Suite / Department / Floor

City	State	Zip Code (9 digits)

County (if in New York)	Telephone Number (w/ extension)	Fax Number

CORPORATE ADDRESS: (indicate where Annual Tax Documents (Form 1099) should be sent)

NOTE: The address supplied will be ignored if Medicaid already recognizes an address for the FEIN listed above.

Attention:	Street Address or PO Box	Suite / Department / Floor

City	State	Zip Code (9 digits)

County (if in New York)	Telephone Number (w/ extension)	e-Mail Address

EMEDNY-436601 (07/12)	2

	{This page may be copied for additional listings}


SERVICE ADDRESS: Only if listed on your license / certification
Attention:		Street Address (PO Box is not acceptable) Suite / Department / Floor

City

State

Zip Code (9 digit)

County (if in New York)

Telephone Number (w/ extension)

Fax Number

SERVICE ADDRESS: Only if listed on your license / certification

Attention:

Street Address (PO Box is not acceptable)

Suite / Department / Floor

City

State

Zip Code (9 digit)

County (if in New York)

Telephone Number (w/ extension)

Fax Number

SERVICE ADDRESS: Only if listed on your license / certification

Attention:

Street Address (PO Box is not acceptable)

Suite / Department / Floor

City

State

Zip Code (9 digit)

County (if in New York)

Telephone Number (w/ extension)

Fax Number

SERVICE ADDRESS: Only if listed on your license / certification

Attention:

Street Address (PO Box is not acceptable)

Suite / Department / Floor

City

State

Zip Code (9 digit)

County (if in New York)

Telephone Number (w/ extension)

Fax Number

SERVICE ADDRESS: Only if listed on your license / certification

Attention:

Street Address (PO Box is not acceptable)

Suite / Department / Floor

City

State

Zip Code (9 digit)

County (if in New York)

Telephone Number (w/ extension)

Fax Number

SERVICE ADDRESS: Only if listed on your license / certification

Attention:

Street Address (PO Box is not acceptable)

Suite / Department / Floor

City

State

Zip Code (9 digit)

County (if in New York)

Telephone Number (w/ extension)

Fax Number

EMEDNY-436601 (07/12)

DISCLOSURE OF OWNERSHIP AND CONTROL

Completion is required by 42 CFR Part 455.104. Failure to provide the information requested will cause the application to be returned. Visit www.health.ny.gov to review definitions and policy found at 18NYCRR, Section 504.1 before completing this form. .

{These pages may be copied for additional listings}

SECTION 1:

Disclosing Entity / Applicant (Entity named on page 2 of this application)

Entity Name

FEIN

NPI (if exempt, leave blank)

Ownership in Applicant (per 42 CFR, Part 455.104(b)(1)(i) – (Entities and/or Individuals) Copy this page to report additional owners.

Name of Individual or Entity					Title (if individual)			Date of Birth (if individual) (MM/DD/YYYY)

Address (Home Address if Individual; Primary Address if Corporation) - Street							City, State & Zip Code (9 digit)

SSN (if individual)	FEIN (if entity)			% of Ownership (if none, put 0%)			NPI or NY Medicaid ID (if none, write None)

For Individuals Only: If you	are related* to another person			with an ownership or control interest			in the Applicant, complete the following:
Name of other Owner:			Relationship to other Owner (parent, child, sibling, spouse):
____________________			_____________________
____________________			_____________________
____________________			_____________________

For Corporations Only: Use the space below to report other business addresses (per 42CFR, Part 455.104(b)(1)(i)):
1)____________________		2)_____________________				3)______________________
_____________________		______________________				_______________________
_____________________		______________________				_______________________


Name of Individual or Entity					Title (if individual)			Date of Birth (if individual) (MM/DD/YYYY)

Address (Home Address if Individual; Primary Address if Corporation) - Street							City, State & Zip Code (9 digit)

SSN (if individual)	FEIN (if entity)			% of Ownership (if none, put 0%)			NPI or NY Medicaid ID (if none, write None)

For Individuals Only: If you are related* to another person with an ownership or control interest in the Applicant, complete the following:

Name of other Owner:	Relationship to other Owner (parent, child, sibling, spouse):
____________________	_____________________
____________________	_____________________
____________________	_____________________

For Corporations Only: Use the space below to report other business addresses (per 42CFR, Part 455.104(b)(1)(i)):

1)____________________ 2)_____________________ 3)______________________

_____________________ ______________________ _______________________

EMEDNY-436601 (07/12)

SECTION 2:

Ownership in Other Disclosing Entities (ODE) (per 42 CFR, Part 455.104(b)(3)) - (Complete if any identified in Section 1 has an ownership or control interest in ODE)

Name (from Section 1)

Name of ODE

NPI or Medicaid ID of ODE

Name (from Section 1)

Name of ODE

NPI or Medicaid ID of ODE

SECTION 3:

Ownership in Subcontractors If the Applicant has an ownership or control interest of 5% or more in a subcontractor and an Owner of the Applicant also has an ownership or control interest in the subcontractor, complete the boxes below. If those identified in this Section have a familial relationship with a person with ownership or control interest in one of these subcontractors, complete Section 4).

Owner’s Name (from Section 1)		Subcontractor Name	Tax Identification Number


	Owner’s Name (from Section 1)	Subcontractor Name	Tax Identification Number

SECTION 4:

Familial Relationship in Subcontractors (Complete if those identified in Section 3 have a *familial relationship with a person with ownership or control interest in one of the subcontractors identified in Section 3).

*parent, child, sibling, spouse

Owner’s Name		Subcontractor’s Name	Name & Familial Relationship


	Owner’s Name	Subcontractor’s Name	Name & Familial Relationship

SECTION 5:

Managing Employees & Those with a Control Interest – Including, but not necessarily limited to, the

following: Facility Administrator, all Members of the Board of Directors, Managing Employees, Compliance Officer, Laboratory Director, Supervising Pharmacist. Include familial relationship to the Applicant (spouse, parent, child, sibling), if any.

Name				Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship


	Name			Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship


Name				Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship

EMEDNY-436601 (07/12)

{This page may be copied for additional listings}

Managing Employees & Those with a Control Interest – (continued)



Name				Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship


	Name			Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship


Name				Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship


	Name			Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship


Name				Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship


	Name			Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship


Name				Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship


	Name			Association Type (see instructions)

Home Address			City & State		Zip Code (9 digit)

SSN		Date of Birth (MM/DD/YYYY)		Familial Relationship

EMEDNY-436601 (07/12)

SECTION 6:

Respond to these questions on behalf of: 1. the Applicant

2.all individuals and entities identified in Section 1

3.any entity in which the Applicant has a 5% or more ownership

1.Have any of the individuals/entities (1, 2 and 3) been terminated, denied enrollment, suspended, restricted by Agreement or otherwise sanctioned by the Medicaid Program in New York or in any other State, Medicare, or any other governmental or private medical insurance program?

 Yes

 No

2.Have any of the individuals/entities (1, 2 and 3) ever been convicted of a crime related to the furnishing of, or billing for, medical care or supplies or which is considered an offense involving theft or fraud or an offense against public administration or against public health and morals in any State?

 Yes

 No

3.Have any of the individuals/entities (1, 2 and 3) ever had their business or professional license or certification, or the license of an entity in which they had an ownership interest over 5% ever been revoked, suspended, surrendered, or in any way restricted by probation or agreement by any licensing authority in any State?

 Yes

 No

4.Is there currently pending any proceedings that could result in the above stated sanctions for the individuals/ entities (1, 2 and 3)?

 Yes

 No

NOTE: If you answered “Yes” to any of the questions above, you must complete and submit the “Prior Conduct Questionnaire” available at www.eMedNY.org.

5. Has there been a change of ownership or control within the last 12 months to any of the entities (1, 2 and 3)?  Yes  No

If “Yes”, provide:

NY Medicaid ID or NPI ____________

Date of Ownership Change _______________ (MM/DD/YYYY)

6. Do you anticipate a change of ownership within the next 12 months to any of the above entities (1, 2 and 3)?  Yes  No

If “Yes”, when do you anticipate the ownership change will occur: ___________ (MM/DD/YYYY)

7. Is the Applicant operated by a management company, or leased in whole or part by another organization?

 Yes

 No If Yes, give date of Change of Operations __________

8. Has there been a change in your lab director or supervising pharmacist within the past year?

 Yes

 No  Not Applicable

9. Does the Applicant/Provider have any unpaid balances owed to the NY Medicaid Program related to this

Business or another entity owned by the Applicant?

 Yes

 No

•	If yes, indicate amount $_____
•	If yes, has payment been arranged?  Yes	 No If yes, attach verification of arrangement.
		If no, this enrollment will be reviewed by the OMIG

EMEDNY-436601 (07/12)

SIGNATURE AND AFFIRMATION

By signing this enrollment form for participation in the New York State Medicaid Program, the Applicant/Provider understands and agrees to the following:

As a Medicaid Provider you agree to comply with the rules, regulations and official directives of the Department including, but not limited to Part 504 of 18NYCRR which can be found at the Department of Health’s website, www.health.ny.gov

In addition, pursuant to 42 CFR, Part 455.105, by enrolling in the Medicaid Program you agree to disclose the following regarding business transactions within the next 35 days upon request of the Department or the Secretary of Health and Human Services.

(1)Information about the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request, and

(2)Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor during the 5-year period ending on the date of the request.

As a Medicaid Provider you agree to abide by all applicable Federal and State laws as well as the rules and regulations of other New York State agencies particular to the type of program covered by this enrollment application.

For those providers for whom the Mandatory Compliance Law applies (see www.OMIG.ny.gov), the Provider has certified via the Office of the Medicaid Inspector General’s web site referenced above that the provider and its affiliates have adopted, implemented and maintains an effective compliance program that meets the requirements of Social Service Law Section 363-d & 18NYCRR, Part 521. A copy of the certification confirmation is included with this enrollment.

Unannounced site visits by Medicaid, CMS or their agents/designated contractors may be a condition of initial and continued enrollment. In addition, the provider and/or owners (defined as at least a 5 % interest) may be required to consent to criminal background checks including fingerprinting.

As a Medicaid Provider you agree to notify this Department immediately of any changes supplied in this enrollment agreement, including impending ownership changes.

The Department may deny or terminate enrollment as a provider in the Medicaid program if it is determined that executive compensation, bonuses, incentives and costs of administration exceed reasonable levels.

Special Note for Ownership Changes: The New York State Medicaid Program uses a uniquely generated Provider ID for internal processing, even for those provider types required to obtain and submit transactions with an NPI. While an FEIN, NPI and other information may change, NY Medicaid may retain the Provider ID for continuity and a smooth transition with no disruptions in payments in most cases. This is especially helpful when clients are associated with these Provider ID’s in the Principle Provider file or the Restricted Recipient file. However, you must be aware that this process also means that retroactive rate adjustments would be paid to or recouped from the new owner without regard to ownership periods. New owners should note that their future Medicaid payments may be reduced due to recoupments against the prior owner. Pended claims for services rendered under the prior ownership will also be paid to the new owner after the change of ownership has been effected. Also, annual reporting of earned income to the Federal Government (Form 1099) will be the total amount paid under the Provider ID for the calendar year and will be reported under the FEIN of the new owner. It is the responsibility of both the new owner and the previous owner to make arrangements under their terms of sale to deal with any accounting and reconciliations between them. The only exception is when the sale only pertains to a portion of the existing enrollment.

WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION ON THIS STATEMENT MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR SECRETARY, AS APPROPRIATE.

__________________________________________________	__________________________________
Print or Type the Name of Person Signing Below	Title

If Applicant / Provider is a legal entity other than a person, the person signing this enrollment document on behalf of the Applicant / Provider warrants that he/she has legal authority to bind the Applicant / Provider. (NOTE: for Changes of Ownership, New Owner or Representative must sign).

________________________________________________________________	_________________________
Signature of Applicant / Provider or Authorized Representative	Date (MM/DD/YYYY)
__________________________________________________________
Name & Telephone Number of Person who Prepared Application

EMEDNY-436601 (07/12)

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1. Start completing the emedny form 436601 with a number of necessary fields. Collect all of the information you need and make sure absolutely nothing is left out!

2. Immediately after this part is completed, go on to enter the suitable information in all these: Rensselaer NY, Revalidation, New Enrollment, Categorys of Service Enter digit, enrolled with appointed Receiver, enrolled required to revalidate, Receivership, NPI unless exempt, FEIN, Change of Ownership, enrolled complying with CFR Part, NY Medicaid ID if currently or, Doing Business As DBA Name, License Assoc With this enrollment, and License Assoc With this enrollment.

YYYY conclusion process described (part 2)

3. Completing of Beds if required, Are you enrolled in Medicare Yes, Applicants eMail Address, Suite Department Floor, Street Address, City, State, Zip Code digits, County if in New York, Telephone Number w extension, Fax Number, PAY TO ADDRESS indicate where, Suite Department Floor, Street Address or, and PO Box is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Guidelines on how to fill out YYYY part 3

4. To move ahead, this step requires filling out several empty form fields. Examples of these are SERVICE ADDRESS Only if listed on, Street Address PO Box is not, City, State, Zip Code digit, County if in New York, Telephone Number w extension, Fax Number, SERVICE ADDRESS Only if listed on, Street Address PO Box is not, City, State, Zip Code digit, County if in New York, and Telephone Number w extension, which you'll find key to moving forward with this particular form.

5. This document has to be finished by filling in this segment. Below you have a comprehensive set of blank fields that have to be filled out with accurate information in order for your form usage to be faultless: County if in New York, Telephone Number w extension, Fax Number, SERVICE ADDRESS Only if listed on, Street Address PO Box is not, City, State, Zip Code digit, County if in New York, Telephone Number w extension, Fax Number, SERVICE ADDRESS Only if listed on, Street Address PO Box is not, City, and State.

Always be really attentive while filling out State and Fax Number, since this is where many people make mistakes.

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