Get Dear Applicant: The New York State Medicaid Program ... - Emedny - Emedny

Completing the Medicaid enrollment application can seem daunting, but this guide will provide you with clear, step-by-step instructions to make the process easier. By following these directions, you can ensure that you properly fill out the application and help facilitate your enrollment in the New York State Medicaid Program.

Follow the steps to effectively complete the Medicaid enrollment form.

1. Press the ‘Get Form’ button to access the Medicaid enrollment application. This will allow you to download and open the form for completion.
2. Fill in the application type. Indicate whether this is a new enrollment, reactivation, or reinstatement by marking the appropriate box clearly.
3. Enter your applicant name exactly as it appears on documents from the Department of Treasury. Ensure that there are no discrepancies to avoid processing delays.
4. Complete the correspondence address section with the address where you would like all correspondence related to your application sent. A physical street address is required.
5. Fill in the service address to accurately reflect the location where services will be provided. This cannot be a P.O. Box; it must be an actual business location.
6. Answer all yes/no questions in the application. If any of the questions are answered yes, you must complete the Prior Conduct Questionnaire available online and provide accompanying documentation.
7. Provide the Federal Employer Identification Number (FEIN) as required. If self-employed, you may need to provide your Social Security Number instead.
8. Ensure the owner's signature is included—this must be an original signature, as stamps or photocopies are not acceptable.
9. Review your application for completeness and accuracy. Forms that are incomplete or contain errors may be returned, delaying the enrollment process.
10. Once the application is complete, save the changes. You may have options to download, print, or share the completed form while ensuring you keep a copy for your records.

Begin your application process online to enroll in the New York State Medicaid Program. Your health coverage is important—take the first step today!