EMEDNY-436901: New York State Medicaid Enrollment Form

In Category(s) of Service, enter the 4-digit code(s) given in the instructions.

Newly enrolling providers (never enrolled) must apply for enrollment through the New York State Medicaid Provider Services Portal (PSP). Paper applications will be returned to providers who submit a paper application and are found eligible to apply using the PSP.

Paper revalidations are no longer being accepted since the revalidation process is transitioning to the Provider Services Portal. Providers will be contacted with instructions on how to revalidate once this transition is complete.

To select Reinstatement/ Reactivation, you must have been previously enrolled in New York State Medicaid and currently be inactive. You must provide your 8-digit NYS Medicaid PID, or this application for reinstatement/reactivation will be returned.

Soon, providers who are inactive but wish to reinstate must do so in the Provider Services Portal (PSP). At that time, this paper option will no longer be accepted.

Enter the Applicant Name exactly as it appears on your license/registration: Last, First, MI.

Enter the Date of Birth (MM/DD/YY), the SSN and the Applicant's e-mail address, which is REQUIRED.

Enter the NPI (Individual), the Specialty and the License #. Enter the State of Licensure if not New York. Mark Yes or No for Limited License?

For the CORRESPONDENCE ADDRESS, a PO Box is not acceptable. Enter Attention, Street Address, Suite / Department/ Floor, City, State, Zip Code (9 digit), County (if in New York), Telephone Number (w/ extension) and Fax Number.

For each SERVICE ADDRESS, where service is provided, do not list a patient's address; valid telephone numbers are required for each service address. Enter Attention, Street Address (a PO Box is not acceptable), Suite / Department/ Floor, City, State, Zip Code (9 digit), County (if in New York), Telephone Number (w/ extension) and Fax Number.

Completion is required by 42 CFR Part 455.104. Failure to provide the information requested will cause the application to be returned.

In SECTION 1, for the Disclosing Entity / Applicant (Individual named on page 2 of this application), enter Name, NPI, Home Address - Street, City & State, Zip Code (9 digits), SSN and Date of Birth.

For Ownership in Applicant (if required by 18NYCRR, Section 504.1(d)(18)(iv)), enter Name of Individual or Entity, % of Ownership, NPI, Address (Home Address if individual), City & State, Zip Code (9 digits), SSN (if indiv)/ FEIN (if entity), Date of Birth (if individual) and Familial Relationship (if individual, if any). Include familial relationship to the Applicant and other Owners (spouse, parent, child, sibling), if any. The address for corporate entities must include every business address.

Complete SECTION 2, Ownership in Other Disclosing Entities(ODE), if any identified in Section 1 has an ownership or control interest in ODE: enter Name (from Section 1), Name of ODE and 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, enter the Owner's Name (from Section 1), Subcontractor Name and Tax Identification Number.

SECTION 4, Familial Relationship in Subcontractors: if those identified in Section 3 have a familial relationship (parent, child, sibling, spouse) with a person with ownership or control interest in one of the subcontractors identified in Section 3, enter the Owner's Name (from Section 1), Subcontractor's Name and Name & Familial Relationship.

In SECTION 5, list Managing Employees, Agents, & Those with a Control Interest - Including, but not necessarily limited to, the Compliance Officer and all Managing Employees. Enter Name, Association Type (see instructions), Home Address - Street, City & State, Zip Code (9 digits), SSN, Date of Birth and Familial Relationship, which is the relationship to the Provider (spouse, parent, child, sibling), if any. If additional space is needed, copy form; all entries must be on the form.

SECTION 6: respond to the questions on behalf of the Applicant, all individuals and entities identified in Sections 1 & 5 and any entity in which the Applicant has a 5% or more ownership. Mark Yes or No for each of questions 1 to 4. All questions must be answered.

If you answered “Yes” to any of the questions above in SECTION 6, you must complete and submit the “Prior Conduct Questionnaire” available at www.emedny.org.

Answer Question 5: do you, including any entity in which you have ownership, have any unpaid balances owed to the NY Medicaid Program? If yes, indicate amount; if yes, has payment been arranged? If yes, attach verification of arrangement. If no to payment arranged, this enrollment will be reviewed by the OMIG.

Sign the Applicant / Provider's Signature line (original; no stamps), and enter the Date and the Name & Telephone Number of Person who Prepared Application.

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.

Mail to: eMedNY PO Box 4603 Rensselaer, NY 12144-4603.

If you will also provide medical services to patients, or as an attending provider will submit a separate claim to Medicaid for your service, do not complete this form.