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Get NY EMEDNY-490602 2014-2021

VE CERTIFICATION WILL APPLY TO ALL CLAIMS SUBMITTED ELECTRONICALLY OR ON PAPER, USING MY (OR THE ENTITY’S) NPI OR MEDICAID PROVIDER IDENTIFICATION NUMBER. THIS CERTIFICATION REMAINS IN EFFECT AND APPLIES TO ALL CLAIMS UNTIL SUPERSEDED BY ANOTHER PROPERLY EXECUTED CERTIFICATION STATEMENT. (4) (Signature) __________________________________(5) (Date) __________________________ (6) (Print Name and Title) ___________________________________________________________ (7) (Telephone #) ________________.

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