Form Emedny 610601 – Fill Out and Use This PDF

NYS MEDICAID INSTITUTIONAL/RATE BASED PROVIDER CHANGE OF ADDRESS FORM

MAIL TO: Computer Sciences Corporation

PO Box 4610

Rensselaer, NY 12144-4610

The New York State Department of Health, Office of Health Insurance Programs, requires all providers to notify the Medicaid Program in writing if they change their CORRESPONDENCE, PAY TO and/or CORPORATE ADDRESS(ES).

In order to ensure that your facility provider file is properly updated, it is necessary that your facility:

1.COMPLETE AND SIGN THE BELOW FORM. PLEASE PRINT CLEARLY. (DO NOT USE RED INK, NOR WHITE-OUT)

2.PREPARE A COVER LETTER, ON YOUR FACILITY’S OFFICIAL LETTERHEAD, FORMALLY REQUESTING THAT YOUR CORRESPONDENCE, PAY TO and/or CORPORATE ADDRESS(ES) BE CHANGED.

3.HAVE THE COVER LETTER SIGNED BY AN AUTHORIZED REPRESENTATIVE.

4.RETURN THE COVER LETTER AND THE COMPLETED FORM TO THE ABOVE ADDRESS.

NOTE: This form can only be used to change the facility’s CORRESPONDENCE, PAY TO and/or CORPORATE ADDRESS(ES). Changes to a facility’s service addresses are based on receipt of official notification concerning changes to the provider’s operating certificates and licenses or information received directly from the State Agency area responsible for this program type.

NPI #: ______________PROVIDER # (if NPI exempt): _________________

PROVIDER NAME:_______________________________________________________________

Enter the Provider name exactly as the facility / program is enrolled.

I wish to change the address to which my CORRESPONDENCE, is sent.

LOCATOR CODE 01: CORRESPONDENCE ADDRESS -

ATTENTION: ________________________________________________________________

Use this line if you wish the mail directed to an agency name, building, department or job title other than the

Provider name.

Street:________________________________________________________________

City:_________________________________________________________________

State:________________________ZIP:_________________COUNTY:____________

Telephone:_____________________________ E-mail address: _____________________________

Please send my MEDICAID CHECKS and/or REMITTANCE STATEMENTS to the address below:

LOCATOR CODE 02: PAY TO ADDRESS.

ATTENTION:______________________________________________________________

Follow the “Attention Line” instructions for Locator Code 01.

STREET:__________________________________________________________________

CITY:_____________________________________________________________________

STATE:________________________ZIP:_______________COUNTY:________________

I wish to change the Corporate address for the FEIN associated with this Provider ID.

Please note that the corporate address should reflect the name and address as it appears on the FEIN documentation. The corporate address is the address to which corporate level correspondence and annual tax documents will be sent. This request MUST be accompanied by a copy of the entity’s FEIN documentation (a W-9 form is not sufficient for this purpose).

ATTENTION:______________________________________________________________

STREET:__________________________________________________________________

CITY:_____________________________________________________________________

STATE:________________________ZIP:_______________COUNTY:________________

Telephone:_____________________________ E-mail address: _____________________________

SIGNATURE OF PROVIDER REPRESENTATIVE:_______________________________________________

PRINT NAME, TITLE & DATE: ______________________________________________________________

A signature is mandatory and must be the facility’s Administrator or an Authorized Representative.

It must be original and legible. A Photocopy or a Stamp is unacceptable for a signature.

Thank you for your cooperation and participation in the New York State Medicaid Program.

EMEDNY-610601 Rate Based Change of Address Form Updated 8/2012