Get Ny Emedny-432301 2020

The NY EMEDNY-432301 form is crucial for providers participating in the Private Duty Nursing Program for Medically Fragile Children, allowing them to certify their training and experience while also enrolling in the PDN Provider Directory. This guide offers step-by-step instructions to help users complete this form accurately and effectively.

Follow the steps to complete the NY EMEDNY-432301 form online.

1. Press the ‘Get Form’ button to obtain the NY EMEDNY-432301 form and open it for editing.
2. Begin with Section One, which is the Certification of Nurse Training and Experience. Input the nurse’s name, NYS license number, Medicaid provider identification number (if enrolled), and National Provider Identifier (NPI). Ensure all fields are accurately filled.
3. In Section One, confirm your certification by signing and dating the form, indicating that you have the required training to provide nursing services to medically fragile children.
4. Move to Section Two if applicable. Here, provide the nurse's name, NYS license number, Medicaid provider identification number (if enrolled), NPI, contact email address, and contact phone number, ensuring accuracy in all entries.
5. In Section Two, confirm your agreement to participate in the PDN Provider Directory by signing and dating the section. This denotes your consent to provide services and to respond to inquiries regarding care for medically fragile children.
6. After completing all relevant sections, review the form for completeness and accuracy, ensuring all required signatures are included.
7. Save your changes, download the completed form, and print it if necessary.
8. Submit the finalized form to eMedNY at PO Box 4610, Rensselaer, NY 12144-4610 to complete the enrollment process.

Complete the NY EMEDNY-432301 form online to ensure you meet the requirements for enhanced reimbursement.