Please complete pages 2 through 5; form must be completed in its entirety.
New enrollment: newly enrolling providers (never enrolled) must apply for enrollment through the New York State Medicaid Provider Services Portal (PSP).
Reinstatement: to select this box, you must have been previously enrolled in New York State Medicaid and currently be inactive.
Revalidation: paper revalidations are no longer being accepted since the revalidation process is transitioning to the Provider Services Portal.
Disclosure of ownership and control: failure to provide the information requested will cause the application to be returned.
| Question | Answer |
|---|---|
| Form Name | EMEDNY-436901 |
| Form Length | 5 pages |
| Fillable? | Yes |
| Fillable fields | 107 |
| Avg. time to fill out | 18 min |
| Edition | 5/26 |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | EMEDNY-436901, EMEDNY 436901, 436901, NY Medicaid enrollment form, New York Medicaid provider enrollment form, NY Medicaid ordering referring attending prescribing form |
| Official source | EMEDNY-436901 (Rev 5/26), |
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