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Nd pay to locations, if applicable. If no changes to these addresses, leave blank. Provider s original signature is required on the bottom of the first page of the form. Pages 1 and 2: list the begin dates for each address update. Page 2: list the following information: old service location(s) with the word CLOSE , if applicable new service location(s) with the word ADD , if applicable Please see below for additional instructions based on provider type.

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Billing related questions can be directed to eMedNY at (800) 343-9000. The 2023 Manual and updated Fee Schedule are now available on eMedNY.

Enter the Member ID. This information may be obtained from the CBIC. Member IDs are assigned by NYS Medicaid and are composed of 8 characters in the format AANNNNNA, where A = alpha character and N = numeric character as shown in Exhibit 2.4. 2-2.

Call the HRA Medicaid Helpline at 888-692-6116 for more information.

Getting Your Medicaid ID Number If you aren't sure what your Medicaid ID number is, you can get this information from Health and Human services either in-person or over the phone by providing them with your identifying information along with a photo ID.

The Electronic Transmitter ID Number (ETIN) is a billing code that allows the electronic submission of New York Medicaid claims for providers as well as checking eligibility. The ETIN is required to maintain Medicaid enrollment, which is required to maintain eligibility for the NY Medicaid EHR Incentive Program.

Licensed entities: Mail a copy of your updated license; approval documents from your state with an official letter requesting the change; copy of the new FEIN IRS letter and form 610501 to: eMedNY, PO Box 4610, Rensselaer, NY 12144-4610. Questions?

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232