Get Emedny-409501 2014-2026

This guide provides clear and detailed instructions for completing the EMEDNY-409501 form online. Whether you are new to the process or need a refresher, this comprehensive resource will support you in filling out the necessary information accurately.

Follow the steps to successfully complete the EMEDNY-409501 form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Determine whether you are seeking enrollment for Medicare crossover claims only. If yes, check the ‘yes’ box and sign on page 4 to bypass the rest of the form.
3. If you did not check the ‘yes’ box, indicate if your business is currently open by selecting either ‘Yes’ or ‘No.’ If you selected ‘Yes,’ provide the opening date. If ‘No,’ indicate the anticipated opening date.
4. List the names of the business owners, their social security numbers, and the percentage of ownership. Ensure that the names match those provided on the Disclosure of Ownership and Control Form.
5. Provide information about the leasehold arrangements, including whether the rent is paid monthly or yearly and any other relevant payment details.
6. Complete the section regarding prior ownership. If applicable, list the NYS Medicaid Provider Number or National Provider Identifier(s) of previous owners.
7. Estimate the dollar value of your current pharmaceutical stock and attach a detailed inventory list.
8. Indicate the percentage of business that will be billed to the NYS Medicaid Program.
9. Identify the banking details for the business, including the bank's name, address, and account numbers. List authorized personnel who can sign corporate checks.
10. Attach a statement identifying individuals authorized to sign NYS Medicaid Program claims, along with their original signatures.
11. List all pharmacists, their license numbers, and their working hours.
12. Detail the services your pharmacy provides, including delivery options, health counseling, multilingual support, and any additional services offered.
13. Explain how your pharmacy promotes its services to customers and include details about mail order or delivery services.
14. Provide contact information for the business's accountant and attorney.
15. Indicate whether you are an out-of-state provider interested in participating in the NYS Medicaid Program and provide the first date of service if applicable.
16. Sign the form as the owner, print your name, and provide the date signed. Ensure all required fields are completed to avoid delays.

Complete your EMEDNY-409501 application online now.