EMEDNY-436701 05/15 NY MEDICAID PROVIDER ENROLLMENT FORM Mail to for Computer Sciences Corporation PO Box 4603 Rensselaer NY 12144-4603 BUSINESSES Category s of Service Enter the 4-digit code s given in the instructions New Enrollment Revalidation enrolled required to revalidate not currently enrolled Change of Ownership enrolled complying with 42CFR Part 455. New York State Medicaid Enrollment Form Thank you for your interest in enrolling with the New York State Medicaid Program* As a Medicaid provider you agree to comply with the rules regulations and official directives of the Department including but not limited to Part 504 of 18 NYCRR i*e* Title 18. Title 18 can be found by choosing the Laws and Regulations link of the Department of Health s website www. health. ny. gov* You will be at financial risk if you render services to Medicaid beneficiaries before successfully completing the enrollment process. Payment will not be made for any claims submitted for services care or supplies....
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How to fill out the NY EMEDNY-436701 online
Completing the New York State Medicaid Enrollment Form (NY EMEDNY-436701) online is a crucial step for providers looking to enroll in the Medicaid Program. This guide provides clear instructions to assist users in accurately filling out the form.
Follow the steps to complete the NY EMEDNY-436701 form online
- Click ‘Get Form’ button to access the enrollment form and open it for editing.
- Indicate the type of provider by selecting either 'Billing Provider' or 'Managed Care Only (Non Billing)'.
- Specify the service category by entering the appropriate 4-digit codes according to the instructions provided.
- Select the appropriate action required: 'New Enrollment', 'Revalidation', 'Change of Ownership', or 'Reinstatement/Reactivation'.
- Fill out the applicant or business name exactly as it appears on your license or IRS assignment letter.
- Input the National Provider Identifier (NPI), Federal Employer Identification Number (FEIN), and other requested details, ensuring your license number and dates are correct.
- Complete the correspondence address, ensuring that valid telephone numbers and email addresses are included.
- Provide the service address where you will render Medicaid services, verifying that no patient's address is listed.
- For those in specific fields, provide details regarding supervising pharmacists or laboratory directors as applicable.
- In the 'Disclosure of Ownership and Control' section, accurately fill in ownership details as per federal guidelines.
- Respond to the series of questions regarding any prior conduct or sanctions against the applicant or associated individuals.
- Verify all information provided and sign the form, ensuring a personal signature is used.
- Once you have completed all sections of the form, save changes, and you will have the option to download, print, or share the form.
Complete your enrollment process online today to ensure compliance and timely payments for your Medicaid services.
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