Get NY EMEDNY-436701 2020-2024

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 furnished before the enrollment date authorized by the Department of Health. If you have any questions contact the eMedNY Call Center at 800 343-9000. Consider printing the Instructions to Complete Enrollment Form before continuing. whom we request personal information why we are requesting information and how we will use it. The information requested will permit proper payments to you as a Medicaid provider according to the provisions of applicable State and Federal Law and Regulations. Collection of this information is authorized by Section 367-b of the Social Services Law. This information will be used as one element of various reviews before payment is made for the goods or services furnished and/or for any post payment audits required by the State or Federal authorities. This information will also be used to satisfy the reporting requirement imposed upon us by State and Federal Regulations e*g* by IRS for payment information reporting purposes. Failure to provide us with the information will prevent establishing the records necessary to enroll you as a Medicaid provider. The information will be maintained by the New York State Department of Health Office of Health Insurance Programs Division of OHIP Operations Bureau of Provider Enrollment Albany New York. 104 NY Provider ID Reinstatement/Reactivation if Applicant was previously excluded/terminated from the Medicaid Program complete the Prior Conduct Questionnaire found at www. eMedNY. org and include it with this Enrollment Form* Applicant / Business Name exactly as it appears on your license/registration if none use name from IRS assignment letter NPI unless exempt FEIN License State of Licensure if not New York License Begin Date MM/DD/YYYY DEA Effective Date MM/DD/YYYY DEA Expiration Date MM/DD/YYYY Doing Business as DBA Name DEA Number Pharmacy Only Are you enrolled in Medicare Applicant s e-Mail Address - REQUIRED Yes No Ownership Code 69-Federal 70-County 71-Municipal 74-For Profit Corp* 75-For Profit Partnership 72-State 73-Voluntary / Not-for-Profit 76-For Profit-Individual 19-Other CORRESPONDENCE indicate where letters and claims forms if any should be sent PO Box not acceptable Attention Street Address Suite / Department/ Floor City State Zip Code 9 digit County if in New York Telephone Number w/ extension Fax Number PAY TO ADDRESS indicate where checks remittance statements should be sent until EFT and e-Remits are in place CORPORATE ADDRESS indicate where Annual Tax Documents Form 1099 should be sent e-Mail Address - REQUIRED PLEASE NOTE Services rendered to Medicaid patients at your service address may not be billed through any other provider number.