Get Group Enrollment Form - Emedny

This guide provides clear instructions for filling out the Group Enrollment Form for the New York State Medicaid Program online. Following these steps will help you successfully complete the enrollment process and ensure compliance with Medicaid regulations.

Follow the steps to efficiently complete the Group ENROLLMENT FORM - EMedNY online.

1. Press the ‘Get Form’ button to obtain the document and display it for editing.
2. Begin by selecting the appropriate category of service from the listed options, such as new enrollment or revalidation.
3. Input your group's or applicant's name exactly as it appears on your IRS assignment letter, followed by the NPI and whether you are enrolled in Medicare.
4. Provide the required ownership code and the group's or applicant's email address.
5. For correspondence details, indicate the name, street address, and additional contact information, ensuring a PO Box is not used.
6. Specify the 'pay to address' where checks and remittance statements should be sent until electronic fund transfers are established.
7. Complete the service addresses section detailing where the service will be provided, including the place of service type.
8. List all physicians and practitioners in your group, including their names, license numbers, and relevant Medicaid provider numbers.
9. Fill out the disclosure of ownership and control section, ensuring information is provided for all individuals or entities with ownership interests.
10. Answer the required questions in the final section regarding any potential sanctions or ownership changes.
11. Sign and date the form, ensuring all necessary fields are completed before submission.

Complete your Group Enrollment Form online today to ensure compliance with New York State Medicaid regulations.