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Get Ny Emedny-436701 2014
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How to fill out the NY EMEDNY-436701 online
This guide provides clear instructions for completing the New York State Medicaid Enrollment Form, known as EMEDNY-436701, online. By following the steps outlined below, users can ensure a smooth and accurate submission process.
Follow the steps to complete your NY EMEDNY-436701 form online.
- Press the ‘Get Form’ button to access the NY EMEDNY-436701 form and open it in the editor.
- Begin by selecting the appropriate category of service from the provided 4-digit codes, and indicate your enrollment type, such as New Enrollment or Revalidation.
- Enter your Applicant or Business Name exactly as it appears on your license or registration. If you have no business name, use the name from your IRS assignment letter.
- Provide your National Provider Identifier (NPI) and Federal Employer Identification Number (FEIN). If exempt from having an NPI, indicate this as well.
- Fill out the License Number, State of Licensure, and important dates such as License Begin Date and DEA Effective and Expiration Dates if applicable.
- If applicable, indicate if you are enrolled in Medicare by selecting 'Yes' or 'No.'
- Complete the correspondence section by providing the attention name, street address, city, state, zip code, and county. Note: PO Box is not acceptable.
- Fill in the Pay To Address section with the required information, indicating where checks and remittance statements should be sent.
- Complete the service address section, ensuring not to list a patient’s address. Include the required attention name and street address.
- For pharmacies, laboratories, or portable x-ray providers, provide the name and NPI of the supervising professional.
- Complete the Disclosure of Ownership and Control sections by accurately listing all individuals and entities with ownership interests.
- Respond to all questions in Section 6 regarding termination, sanctions, or ownership changes.
- Sign and date the form within the Signature and Affirmation section. Ensure the signature is original and not stamped.
- Once all sections are completed and checked for accuracy, save your changes, download the form, print a hard copy, or share it as needed.
Start filling out the NY EMEDNY-436701 online today!
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The time it takes to get credentialed through Medicare can vary, but it typically ranges from 30 to 90 days. Factors impacting this timeline include the completeness of your application and the volume of applications being processed. Keeping track of your application status through the appropriate channels can help manage your expectations during this process.
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