Get Ny Emedny-427601 2016-2026

Filling out the NY EMEDNY-427601 form correctly is essential for requesting prescription footwear through New York State Medicaid. This guide will provide you with detailed, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the NY EMEDNY-427601 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Select the purpose of the request by checking one of the following boxes: 'New Certification', 'Renewal', or 'Change of Employment'. This informs the Department of Health about the nature of your submission.
3. Enter the Medicaid provider name, Medicaid provider number, and National Provider Identifier (NPI) in the designated fields. Ensure all information is accurate to avoid processing delays.
4. Provide the names of all certified orthotists, prosthetists, or pedorthists associated with your request. Each name should be listed separately.
5. Indicate the relationship of the certified individual to your company by selecting either 'Owner' or 'Employee'. If neither applies, provide an explanation in the space provided.
6. List any other locations where the certified individuals are currently employed and dispense shoes. This may be necessary for verifications.
7. Attach a copy of the current certification for at least one employee or owner. Check the relevant organization for certification from either the American Board for Certification in Orthotics, Prosthetics, and Pedorthics, Inc. or the Board for Certification/Accreditation, International.
8. If applicable, submit a copy of certified fitters' licenses and list their names within the form.
9. For changes in employment, mark the appropriate box to indicate if it is for a new employee or if an employee has left. Fill in the required dates and names as prompted.
10. Lastly, provide the printed name and original signature of the owner and the date. Ensure all required signatures are provided to complete the submission process.
11. Once all sections are completed, save changes, download, print, or share the form as needed for your records.

Begin completing your NY EMEDNY-427601 form online today for a seamless submission process.