Get Ny Emedny-436701 2015

This guide provides clear and comprehensive instructions for completing the NY EMEDNY-436701 form online. By following each step, you will ensure that your enrollment as a Medicaid provider is completed accurately and efficiently.

Follow the steps to successfully complete the NY EMEDNY-436701 online.

1. Press the ‘Get Form’ button to access the enrollment form and open it in the appropriate editor.
2. Select the category of service by entering the required 4-digit code(s) as provided in the form instructions.
3. Indicate the type of enrollment by selecting one of the available options: New Enrollment, Revalidation, Change of Ownership, or Reinstatement/Reactivation.
4. Complete the applicant/business name exactly as it appears on your license or registration. If you do not have a license, use the name from your IRS assignment letter.
5. Fill in the National Provider Identifier (NPI), Federal Employer Identification Number (FEIN), and relevant license information, including license number and state of licensure.
6. Provide the dates for the license begin, DEA effective, and DEA expiration as specified in the form.
7. Indicate if you are enrolled in Medicare by checking the appropriate box.
8. Complete the correspondence address section to specify where letters and claims forms should be sent, ensuring not to use a PO Box.
9. Fill out the pay-to address section, indicating where checks and remittance statements should be sent until electronic payment options are established.
10. Provide the service address where services will be rendered, making sure not to list a patient’s address.
11. If applicable, enter the details of the supervising pharmacist, laboratory director, or supervising physician, ensuring they are actively enrolled in the New York Medicaid Program.
12. Complete the Disclosure of Ownership and Control sections by providing necessary ownership details as required by the form.
13. Review and answer all questions in Section 6 concerning any sanctions, ownership changes, and owed balances related to the Medicaid Program.
14. Sign and date the application, ensuring that the signature is original and not stamped.
15. Finally, save your changes, and download or print the completed form for your records.

Complete your documentation online to ensure timely enrollment in the New York State Medicaid Program.