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How to fill out the Emedny 490601 online
The Emedny 490601 is an important form used for certification as a provider in the New York State Medical Assistance Program. This guide will provide you with clear, step-by-step instructions on how to complete the form accurately and efficiently online.
Follow the steps to complete the Emedny 490601 form.
- Press the ‘Get Form’ button to obtain the form and open it in the online editor.
- Locate Field 1 and enter the 10-digit Electronic/Paper Transmitter Identification Number (ETIN) if adding a provider ID number to an existing ETIN. If you are obtaining a new ETIN, leave this field blank.
- In Field 2, enter the name of the billing service if applicable. If not utilizing a billing service, leave this blank.
- Proceed to Field 3 and enter the current date, on which you are submitting the certification.
- In Field 4, write the name of the provider whose signature is being notarized.
- Complete Field 5 with the 10-digit National Provider Identifier (NPI). If you are exempt from the NPI requirement, skip this step.
- If you are exempt from the NPI, enter the 8-digit Medicaid Provider Number in Field 6.
- In Field 7, provide the original signature of the individual listed in Field 4.
- In Field 8, enter the date when the signature was made.
- For Field 9, print the name and title of the individual signing in Field 7.
- Fill in Field 10 with the telephone number of the person who signed in Field 7.
- If available, add the email address of the person in Field 11.
- Field 12 is for the Notary Public to complete. Ensure that the notary includes their signature, seal, and the expiration date.
- Review all filled fields for accuracy. If satisfied, you can either print the completed form or save it according to your needs.
Complete your Emedny 490601 certification process online today to ensure timely and accurate Medicaid billing.
Filing an XBRL requires you to convert your financial data into a specified format compliant with the XBRL taxonomy. This format enhances the usability of financial statements for investors and regulators alike. To ensure accuracy with Emedny 490601 guidelines, consulting resources from USLegalForms can be beneficial.
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