Get Laboratory Information Request - Form #429801 - Emedny

Filling out the Laboratory Information Request - Form #429801 - EMedNY online can be a straightforward process if you follow the right steps. This guide provides clear instructions for each section of the form, ensuring that all required information is accurately provided.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by listing the name(s) of the business owner(s) along with their social security numbers and ownership percentages in the first section. Ensure these match the names on question #5 of the Disclosure of Ownership and Control Form. Include any relevant National Provider Identifiers, Medicaid provider numbers, or professional licenses.
3. In the next section, indicate whether the owners are involved in other businesses providing services for Medicaid beneficiaries. If applicable, list their names.
4. Provide details of all business locations, including full addresses and whether each location is a main site or collection station. Specify if the facility is fixed or mobile.
5. Include leasehold arrangements by specifying whether rent is paid monthly or annually, and attach a signed copy of the current lease. Provide the owner’s name and address of the properties used.
6. If applicable, include documentation relating to any recent acquisition of the laboratory, like promissory notes or sales agreements.
7. Identify in-house personnel including their titles and qualifications. Use the appropriate attachments to provide complete lists of staff, licensed employees, and their respective licenses.
8. Detail services your laboratory offers to physicians and clinics, specifying the nature of the service and identifying the orderers.
9. State whether your laboratory employs sales agents and explain their compensation structure. Attach contracts if available.
10. List any third-party health insurers you are contracted with and the percentage of your business billed to the NYS Medicaid Program.
11. Indicate if you seek Medicaid enrollment for specialized testing areas and specify if using third-party management.
12. Detail specimen transportation arrangements, including schedule and method of transport.
13. Complete the section on test result reporting, including how reports are generated and shared.
14. List bank accounts to be used by the laboratory and individuals authorized to sign checks.
15. Before submitting, ensure that your signatures are provided for Medicaid claims and document any referral work with other laboratories.
16. Finally, review all provided information, save any changes made, and download or print the completed form for your records.

Start completing your Laboratory Information Request - Form #429801 - EMedNY online today!