Get Emedny Form 361501

Filling out the Emedny Form 361501 online is a crucial step for healthcare providers in the New York State Medicaid program to obtain prior approval for services. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the Emedny Form 361501 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out Field 1, 'Provider Type.' Indicate the service type by placing an X in the box labeled 'Physician.'
3. In Field 2, 'Order Date,' indicate the exact date on which you are submitting the request. Use the format month, day, year (MMDDYYYY).
4. For Field 3, 'ID / License Number,' leave this field blank.
5. In Field 4, 'Prof Code,' this field should also remain empty.
6. Fill in Field 5, 'Prescribed By (Name),' with the prescriber's name; however, this field should be left blank initially.
7. In Field 6, provide the address details of the prescriber.
8. Provide the 'Provider Telephone Number' in Field 7, leaving it blank if not applicable.
9. In Field 8, 'Prescriber Signature,' the physician must sign their name.
10. Complete Field 9 with the 'Primary Diagnosis' using the ICD-9-CM code corresponding to the client's condition.
11. If applicable, enter the 'Secondary Diagnosis' in Field 10. Leave it blank if there is no secondary condition.
12. Input the 'Client ID' in Field 11, ensuring it follows the eight-character WMS ID format.
13. In Field 12, enter the client's name in the order specified: last name followed by the first name.
14. Provide the full address of the client in Field 13.
15. Indicate the date of birth of the client in Field 14 using the month, day, year format.
16. Input the client’s telephone number in Field 15.
17. For Field 16, mark the appropriate box for the client’s gender - use 'M' for Male or 'F' for Female.
18. In Field 17, provide any necessary 'Order Description / Medical Justification' relevant to the request.
19. Fill out Field 18 with the 'Servicing Provider ID' number assigned by the New York State Department of Health.
20. Input the servicing provider's name in Field 19 exactly as registered.
21. Enter the provider’s address in Field 20 as it appears in your records.
22. Provide the office telephone number in Field 21.
23. Specify the location code in Field 22 for receiving correspondence related to the prior approval.
24. Field 23, 'Drug Code (NDC),' should remain blank.
25. Input the 'Procedure / Item Code' in Field 24, referring to the corresponding service code.
26. If necessary, include a modifier in Field 25.
27. Leave Field 26, 'Rental?' blank.
28. In Field 27, provide a description that corresponds to the procedure/item code.
29. In Field 28, enter the quantity requested for the procedures or items.
30. Field 29 can remain blank.
31. In Field 30, indicate the total amount requested for the procedures.
32. Lastly, enter 'A1' in Field 31, identifying the agency responsible for review.
33. Once all fields are completed, save your changes, and you can choose to download, print, or share the form as needed.

Complete your Emedny Form 361501 online now for faster processing.