Get Instructions To Complete Enrollment Form - Emedny - Emedny

Completing the Enrollment Form for EMedNY is an essential step for providers seeking to offer ambulance services. This guide will provide you with clear, step-by-step instructions to ensure your form is filled out correctly and efficiently online.

Follow the steps to successfully submit your enrollment form online.

1. Press the ‘Get Form’ button to obtain the Enrollment Form and open it for editing.
2. Complete all items on the form as directed. Ensure that you fill in all required fields as failing to do so may lead to delays in processing your enrollment.
3. Attach the required documents to the form. This includes the IRS Assignment Letter, New York State Ambulance Service Certification, Medicare participation letter, and any other specified documents.
4. In the 'Category(s) of Service' section, write '0601' for ambulance services and select the appropriate enrollment status: New Enrollment, Revalidation, or Reinstatement/Reactivation.
5. Fill out the DBA Name and leave the DEA Number and Dates fields blank if not applicable. Ensure you include your Medicare enrollment details.
6. Indicate your role by selecting the correct letter (B, F, H, M, P, or U) corresponding to your position within the organization.
7. Complete the signature field with an original signature. Ensure that all handwritten text is legibly printed in black or blue ink, as red ink will not be accepted.
8. Make a copy of the entire form with all attachments for your records before submission.
9. Once you have ensured all fields are completed, submit the form along with all required documents as instructed.
10. After submission, you may download, print, or share your completed form for your records.

Begin completing your documents online today to facilitate your enrollment process.