Get Emedny 426601

The Emedny 426601 is an essential form for individuals looking to enroll in the New York State Medicaid Program as providers. This guide offers a detailed, step-by-step approach to help you complete the form accurately and efficiently online.

Follow the steps to fill out the Emedny 426601 form.

1. Click the 'Get Form' button to access the Emedny 426601 form online and open it for editing.
2. Begin the form by specifying the category of service applicable to your practice, such as physician group or dental group.
3. Select the type of application you are submitting, whether it is a new enrollment, reactivation, or reinstatement.
4. Clearly enter the name of the applicant as it appears on the tax documents issued by the Internal Revenue Service.
5. Input your National Provider Identifier (NPI) and Federal Employer Identification Number (FEIN). Ensure that the information is accurate and current.
6. Fill in the correspondence address where all communication will be sent. This should be a physical address, not a P.O. Box.
7. Complete the pay-to address if you require checks to be sent to a different location than the correspondence address, or indicate 'SAME' if they will be sent to the correspondence address.
8. Indicate the service address, ensuring it reflects the physical location where services will be provided. If you use multiple locations, you will need to provide additional service addresses.
9. Respond to all yes/no questions accurately. If any answers warrant further explanation, complete the necessary questionnaire as directed.
10. Ensure that the form is signed and dated by the owner or a board member, as original signatures are required.
11. After completing the form, review all fields for accuracy and completeness. Save any changes, and if necessary, download or print the form for your records before submission.

Complete your Emedny 426601 application online today to ensure your enrollment in the New York State Medicaid Program.