Get Emedny 436801 2020-2025

Filling out the Emedny 436801 form is an essential step for enrolling in the New York State Medicaid Program. This guide provides you with a comprehensive overview and step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to successfully complete the Emedny 436801 online.

1. Press the ‘Get Form’ button to access the Emedny 436801 form. This will allow you to view and fill out the required information online.
2. Begin by selecting the appropriate category of service from the four-digit code options. Indicate whether you are applying for new enrollment, reinstatement/reactivation, or revalidation.
3. Provide your name exactly as it appears on your license or registration. Fill in your National Provider Identifier (NPI), license number, state of licensure (if applicable), and Social Security Number (SSN).
4. Enter your email address, and if applicable, your DEA number along with its effective and expiration dates. If you are part of a group, indicate whether you have a private practice and if you are enrolled in Medicare.
5. Fill out the correspondence section to specify where letters and claims should be sent. Provide the suitable attention name, complete street address, city, state, zip code, county (if in New York), telephone number, and fax number.
6. Complete the pay-to address section to indicate where checks and remittance statements should be directed until electronic funds transfer (EFT) and electronic remittance (e-Remits) are established.
7. In the service address sections, specify where services will be provided. Make sure not to list a patient’s address. Fill in the required fields related to the type of practice and place of service.
8. Provide the information required for the disclosure of ownership and control, including the names, addresses, and percentage of ownership for any individuals or entities involved.
9. Answer the required questions regarding any terminations, convictions, or unpaid balances related to the Medicaid program, ensuring all sections are appropriately filled.
10. Complete the signature and affirmation section at the end of the form. Ensure that the signature is original and include the name and telephone number of the person who prepared the application.
11. Once all necessary fields have been filled out, review the form for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete your Emedny 436801 enrollment form online to ensure timely processing of your Medicaid application.