Follow the steps to complete the NY EMEDNY-424402 online successfully.

1. Click the ‘Get Form’ button to access the NY EMEDNY-424402 form and open it in your preferred editing platform.
2. Carefully fill out all items on the form. It is crucial to complete every required field, as failing to do so might result in the return of your form, delaying your enrollment.
3. At the top of the enrollment form, select one of the billing options by checking the corresponding box: either ‘Billing Provider’ for direct billing to NYS Medicaid or ‘Managed Care Only’ if you are contracted with a managed care organization.
4. In the ‘Category(s) of Service’ section, enter the appropriate 4-digit code that matches your service type, such as 0602 for ambulette, 0603 for upstate taxi, etc.
5. Select your enrollment status by checking the relevant box: ‘New Enrollment’, ‘Revalidation’, or ‘Reinstatement/Reactivation’ based on your current enrollment situation.
6. Fill in the association type by entering the corresponding letter that represents your role, such as ‘B’ for Board of Directors Member or ‘F’ for Facility Administrator.
7. Refer to the additional requirements section and ensure you gather all necessary documents that must accompany your application, such as the IRS Assignment Letter and other required certifications.
8. Review the attestation section carefully. Make sure to sign and date the form, as an original signature is mandatory.
9. After completing the form, save your changes, and prepare to download, print, or share the form as needed for your records.

Complete the NY EMEDNY-424402 online to ensure your enrollment in the New York State Medicaid program.