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Get NY EMEDNY-436901 2014

G, referring, attending or prescribing practitioner only (attending providers should use this form if their name and NPI will only appear on the hospital’s claim). These practitioners will not submit claims to Medicaid and, therefore, will not receive payment from the Medicaid Program. If you will also provide medical services to patients, or as an attending provider will submit a separate claim to Medicaid for your service, do not complete this form. Visit www.eMedNY.org and complete the enro.

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