Get Emedny 424601 06 16

The Emedny 424601 06 16 form is an essential document required for transportation information request in relation to medical services. This guide will help you navigate the process of completing the form online, ensuring you provide all necessary information effectively.

Follow the steps to fill out the Emedny 424601 06 16 form online.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate whether you are an out-of-state provider of medical services interested in participation for one occurrence of care delivered to one beneficiary. Select 'Yes' or 'No' and if 'Yes', include the date of service. If this applies, you must sign the form on page 6 and do not continue with the rest of the form.
3. If you are an out-of-state provider interested in participation for services over a maximum of 60 days, please indicate 'Yes' or 'No'. Provide the date range of service if applicable, and again, if 'Yes', sign the form on page 6.
4. List the names of all other current or former companies owned or operated by individuals listed in Section 1. Include the company name, FEIN or provider number, and all owners.
5. Provide information about any other companies owned or operated by the relatives of individuals in Section 1. Indicate the relationship and provide similar details as in Step 4.
6. Indicate if there are other Medicaid providers at your service address. If 'Yes', list their names.
7. List the professional licenses held by the owners, including the last name, first name, license number, profession, and NPI or Medicaid provider number.
8. Answer whether any of the owners operate a medical care institution; provide details if applicable.
9. Estimate the percentage of services you provide in defined categories like wheelchair confinement, ambulating with assistance, and fully ambulatory.
10. State the geographic area(s) you are certified to serve by the Department of Transportation.
11. Indicate the exact days and corresponding hours you provide transportation services for livery/taxi and ambulette.
12. Estimate the percentage of business that will be billed to the NYS Medicaid Program.
13. Provide the banking information needed by your business, including name, address, and account numbers.
14. List authorized personnel who can sign checks, along with their social security numbers.
15. Provide a history of past employment for specified individuals, detailing positions and duties.
16. Outline leasehold arrangements for your business location, ensuring any leases are attached.
17. Detail vehicle information, indicating owned or leased vehicles, along with VINs.
18. Answer if any owners have been subcontractors for medical transportation providers, and provide their details if applicable.
19. If applicable, answer any questions regarding changes of ownership and agree to any conditions outlined.
20. After completing the form, save your changes, then download, print, or share the form as needed.

Complete your Emedny 424601 06 16 form online today to ensure a smooth enrollment process.