Get Etin Application

The Etin application is essential for enrolled providers in New York State wishing to obtain an Electronic/Paper Transmitter Identification Number. This guide provides clear instructions to help you confidently complete the application online.

Follow the steps to complete your Etin application successfully.

1. Click the ‘Get Form’ button to access the Etin application and open it for editing.
2. Begin with section one by entering your provider name clearly in the designated field.
3. In section two, fill out your provider address, ensuring that you include your street, city, state, and zip code. Don't forget to provide your telephone number.
4. Next, complete section three by indicating the administrator's name and their contact number, ensuring you include the extension if applicable.
5. In section four, input the contact person's name who will handle inquiries about the application.
6. Section five requires you to provide the contact telephone number associated with the individual mentioned in section four.
7. If applicable, fill out section six with your 10-digit National Provider ID (NPI), noting that this field is required unless you have an exemption.
8. For section seven, you must include the MMIS provider number if you are exempt from having an NPI.
9. The application must be signed by an authorized individual. Ensure that their name is printed clearly, and they affix their signature, title, and date in the respective fields.
10. Finally, review all entries for accuracy. Once you have ensured everything is correct, save your changes. You can then download, print, or share the completed application as needed.

Don't wait—complete your Etin application online today!