Get Request For Participation As A Group Member - Form ... - Emedny - Emedny

Completing the Request For Participation As A Group Member form for EMedNY is essential for practitioners looking to affiliate or disaffiliate from a group practice. This guide will provide you with clear and supportive instructions for each section of the form to ensure that you fill it out correctly.

Follow the steps to fill out the form accurately.

1. Press the ‘Get Form’ button to access the document and open it for completion.
2. Choose the appropriate request option by selecting either the 'Request to Affiliate to a Group Practice' or 'Request to Disaffiliate'. Based on your choice, complete the relevant sections (B or C).
3. In Section A, provide the necessary details for both the practitioner and the group. Ensure you include names and NPI numbers, as these fields are required. The Medicaid ID is optional.
4. Specify the effective date for the affiliation or disaffiliation. Be mindful that if the date is in the past and exceeds 90 days from the submission date, it will not be accepted.
5. If you are requesting to affiliate, in Section B, confirm your agreement by signing and dating the form. This indicates your commitment to the Medicaid Program.
6. For disaffiliation requests, complete Section C by signing and dating your section and including a group practice representative's signature, if necessary.
7. Once you have completed all sections and verified the information, save your changes. You can then download, print, or share the form as required.

Complete your documents online to ensure a smooth process.