Emedny 436701 Form PDF Details

The New York State Medicaid Enrollment Form, known as EMEDNY-436701, serves as a critical gateway for providers aiming to offer services to Medicaid beneficiaries within New York State. This document outlines the necessary steps and requirements for enrollment, emphasizing compliance with specific state and federal laws and regulations, such as Part 504 of 18 NYCRR. Providers are cautioned about the financial risks involved when rendering services to Medicaid beneficiaries prior to the successful completion of the enrollment process, highlighting the importance of adherence to the state's Department of Health directives. The form meticulously collects detailed information on providers, including personal data, professional credentials, and business particulars to ensure proper payment and facilitate post-payment audits as per state and federal oversight. It also delves into the disclosure of ownership and control, a requirement that must be met to avoid application rejection. This detailed approach underscores New York State's commitment to maintaining a transparent and accountable Medicaid program, safeguarding both providers and beneficiaries by ensuring that services are rendered by qualified entities. Interested applicants are advised to engage with the comprehensive instructions provided to complete the enrollment process effectively, with assistance available through the eMedNY Call Center for any arising questions.

QuestionAnswer
Form NameEmedny 436701 Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesny medicaid form, ny emedny436701, ny emedny436701 form, ny medicaid businesses

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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.

Consider printing the Instructions to Complete Enrollment Form before continuing. Please complete pages 2 through 8; form must be completed in its entirety.

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, Albany, New York.

EMEDNY-436701 (10/20)

1

NY MEDICAID PROVIDER ENROLLMENT FORM

Mail to:

for

 

BUSINESSES

eMedNY

Only Choose One:

 

 

PO Box 4603

 

 

Rensselaer, NY 12144-4603

Billing Provider

Managed Care Only (Non Billing)

 

 

 

 

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

 

 

 

 

New Enrollment

 

Revalidation

Change of Ownership

 

 

(enrolled; required to revalidate)

(enrolled, complying with 42CFR Part 455.104)

(not currently enrolled)

 

 

NY Provider ID # ___________

 

 

 

 

 

 

Reinstatement/Reactivation

– if Applicant was previously

excluded/terminated from the Medicaid

Program, complete the Prior Conduct Questionnaire found at www.eMedNY.org and include it with this Enrollment Form.

Applicant / Business Name (exactly as it appears on your license/registration; if none use name from IRS assignment letter)

NPI (unless exempt)

 

 

 

FEIN

 

 

 

 

 

 

 

 

 

 

 

License #

 

 

State of Licensure if not New York

License Begin Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

Doing Business as (DBA) Name

 

 

 

 

 

 

 

 

 

 

 

 

 

DEA Number (Pharmacy Only)

 

DEA Effective Date (MM/DD/YYYY)

DEA Expiration Date (MM/DD/YYYY)

 

 

 

 

 

 

 

Are you enrolled

 

 

 

Applicant’s e-Mail Address - REQUIRED

 

in Medicare?

Yes

No

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

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 digit)

 

 

 

 

 

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 digit)

 

 

 

County (if in New York)

Telephone Number (w/ extension)

Fax Number

 

 

 

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

Attention:

Street Address or PO Box

Suite / Department/ Floor

 

 

 

City

State

Zip Code (9 digit)

 

 

 

County (if in New York)

Telephone Number (w/ extension)

e-Mail Address - REQUIRED

 

 

 

EMEDNY-436701 (10/20)

2

PLEASE NOTE:

Services rendered to Medicaid patients at your service address may not be billed through any other provider number. If you provide services at your service location that are subsequently billed through another provider number (including a provider number issued to another location under the same ownership) your application will be denied and action will be taken against the billing provider.

SERVICE ADDRESS: (where service is provided) – DO NOT LIST A PATIENT’S ADDRESS

(see instructions)

*Valid Telephone numbers are required for each service address.

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

If the Applicant is a Pharmacy, Laboratory or a Portable X-Ray provider, please provide the Name and NPI of the Supervising Pharmacist, Laboratory Director or Supervising Physician, respectively.

PLEASE NOTE: If this individual is not actively enrolled in the NY Medicaid Program, s/he must complete the appropriate enrollment form found at www.eMedNY.org.

Name:

NPI:

EMEDNY-436701 (10/20)

3

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. Click here to review definitions and policy found at 18NYCRR, Section 504.1 before completing this form. {If additional space is needed, copy form; all entries must be on the form}.

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 (for individual)

FEIN (for 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 & Optical Establishments 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 (for individual)

FEIN (for 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 & Optical Establishments Only: Use the space below to report other business addresses (per 42CFR, Part 455.104(b)(1)(i)):

1)____________________ 2)_____________________ 3)______________________

_____________________ ______________________ _______________________

_____________________ ______________________ _______________________

EMEDNY-436701 (10/20)

4
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

SECTION 2:

Ownership in Other Disclosing Entities (ODE) (per 42 CFR, Part 455.104(a)(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

 

 

 

Owner’s Name

Subcontractor’s Name

Name & Familial Relationship

 

 

 

 

 

 

Owner’s Name

Subcontractor’s Name

Name & Familial Relationship

 

 

 

SECTION 5:

Agents, 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, Employee/Lifestyle Coach (although unusual, if None, indicate NONE in the first "Name" field below). Include familial relationship to the Applicant (spouse, parent, child, sibling), if any.

Completion of all fields is required by 42 CFR Part 455.104. Failure to provide the information requested will cause the application to be returned. Click here to review definitions and policy found at 18NYCRR, Section 504.1. If additional space is needed, copy form; all entries must be on the form.

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-436701 (10/20)

5

{If additional space is needed, copy form; all entries must be on the form}

Agents, 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-436701 (10/20)

6

SECTION 6:

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

2.all individuals and entities identified in Sections 1 & 5

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

Please continue and Answer Questions 5 through 7.

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.

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-436701 (10/20)

7

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

(https://omig.ny.gov/compliance/compliance), the Provider has certified via the CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID that the provider adopted, and implemented, where applicable, 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.

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.

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.

__________________________________________________

_________________________

Applicant / Provider’s Signature (original; no stamps)

Date (MM/DD/YYYY)

__________________________________________________________

 

Name & Telephone Number of Person who Prepared Application

 

EMEDNY-436701 (10/20)

8

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Step # 1 for filling in ny medicaid businesses

2. The next step would be to complete all of the following blank fields: DEA Number Pharmacy Only, DEA Effective Date MMDDYYYY, DEA Expiration Date MMDDYYYY, Are you enrolled in Medicare Yes, Applicants eMail Address REQUIRED, CORRESPONDENCE indicate where, Suite Department Floor, Street Address, City, State, Zip Code digit, County if in New York, Telephone Number w extension, Fax Number, and PAY TO ADDRESS indicate where.

Fax Number, Applicants eMail Address REQUIRED, and DEA Number Pharmacy Only inside ny medicaid businesses

3. This next portion will be focused on City, State, Zip Code digit, County if in New York, Telephone Number w extension, eMail Address REQUIRED, and EMEDNY - fill out each of these fields.

ny medicaid businesses conclusion process outlined (part 3)

4. To go onward, this step involves typing in a couple of blanks. Included in these are SERVICE ADDRESS where service is, Street Address PO Box is not, Suite Department Floor, City, State, Zip Code digit, County if in New York, Telephone Number w extension, Fax Number, If the Applicant is a Pharmacy, Name, and NPI, which are vital to continuing with this particular form.

Writing part 4 of ny medicaid businesses

5. Now, the following final section is precisely what you need to complete before closing the form. The fields in this case include the following: Completion is required by CFR, Entity Name, FEIN, NPI if exempt leave blank, Ownership in Applicant per CFR, Name of Individual or Entity, Title if individual, Date of Birth if individual, Address Home Address if Individual, City State Zip Code digit, SSN for individual, FEIN for entity, of Ownership if none put, NPI or NY Medicaid ID if none, and For Individuals Only If you are.

ny medicaid businesses completion process outlined (stage 5)

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