Get Emedny 490501

Filling out the Emedny 490501 form online is an important task for providers submitting claims to New York's Medicaid program. This guide provides a step-by-step approach to help you navigate each section of the form effectively.

Follow the steps to successfully complete the Emedny 490501 form.

1. Click the ‘Get Form’ button to access the form and open it in the editor.
2. In the first field, enter the ETIN (Electronic/Paper Transmitter Identification Number). If you are requesting a new ETIN, leave this field blank.
3. If applicable, provide the billing service name in the second field. If you are not associated with a billing service, you may leave this field empty.
4. Enter the date in the third field when you are submitting the certification. This is the date of completion.
5. Fill in the provider name in the fourth field, indicating the name of the provider whose claims are covered by this certification.
6. In the fifth field, list the 10-digit National Provider Identifier (NPI). This is a required entry unless you have an exemption.
7. If you are exempt from NPI, provide the 8-digit Medicaid Provider Number in the sixth field.
8. Obtain the signature of the authorized individual in the seventh field, ensuring that it is an original signature.
9. Document the date of the signature in the eighth field.
10. Print the name and title of the individual whose signature is recorded in the seventh field in the ninth field.
11. Include the telephone number of the person whose signature appears in the previous field in the tenth field.
12. If available, add the email address in the eleventh field.
13. The twelfth field is to be completed by a Notary Public. Ensure the notary signs and provides their seal or stamp.
14. Review all entries for accuracy. Save any changes made before proceeding.
15. Once confirmed, you may download, print, or share the completed form as needed.

Begin filling out the Emedny 490501 form online today to streamline your claims process.