Get Emedny/medicaid Management Information System ... - Emedny

This guide provides detailed instructions on how to complete the EMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM certification statement. Whether you are filling out this form for the first time or need a refresher, this comprehensive guide will support you through each step.

Follow the steps to successfully complete the certification statement.

1. Press the ‘Get Form’ button to obtain the form and open it in your editing tool.
2. In Field 1, enter the provider name accurately as it appears on their official documents. This is important for verification purposes.
3. For Field 2, include the 10-digit National Provider Identifier (NPI).This is a required field unless exempted.
4. If your entity is exempt from having an NPI, fill out Field 3 with the corresponding Tax ID number.
5. In Field 4, the authorized individual must provide their signature. Ensure this is an original signature, as copies may not be accepted.
6. Indicate the date of signing in Field 5. This confirms when the certification statement was completed.
7. For Field 6, print the name and title of the signer as it corresponds to Field 4.
8. Input a valid telephone number in Field 7 where the signer can be reached if additional information is required.
9. If available, provide an email address in Field 8 to facilitate communication related to the claim.
10. Field 9 must be completed by a Notary Public. Ensure the notary includes their signature, seal, and expiration date.
11. Review all fields to confirm that the information is accurate and clear. Any errors should be corrected before submission.
12. Once all fields are completed, you may save changes, download, print, or share the completed form as necessary.

Start filling out your EMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM certification statement online today to ensure compliance and proper claim submissions.