Get Ny Emedny-436901 2014

The New York EMEDNY-436901 enrollment form is essential for practitioners seeking to enroll in the New York State Medicaid Program as ordering, referring, attending, or prescribing practitioners. This guide provides clear steps to successfully complete the form online.

Follow the steps to effectively complete the NY EMEDNY-436901 form online.

1. Press the ‘Get Form’ button to obtain the enrollment form and open it in your preferred editor.
2. Begin by selecting your enrollment type: New Enrollment, Reinstatement/Reactivation, or Revalidation, using the appropriate checkboxes.
3. Enter the 4-digit category codes for the services you will provide, as detailed in the instructions.
4. Fill in your NY Provider ID number, if applicable, ensuring that the number is accurate.
5. Provide your name exactly as it appears on your license/registration, along with your date of birth and Social Security Number (SSN).
6. Input your email address as it is a required field. Include your National Provider Identifier (NPI) for both individual and group, if affiliated.
7. Specify your medical specialty and license number, and indicate your state of licensure if it is not New York.
8. For the correspondence address, ensure it is a physical address as PO Boxes are not acceptable. Fill in all required fields including attention, street address, city, state, zip code, county, telephone number, and fax number.
9. Repeat the process for the service address where the services will be provided, making sure to not include any patient addresses.
10. Complete the Disclosure of Ownership and Control sections, providing details on ownership interests, home addresses, and relationships.
11. Respond truthfully to all questions in Section 6 regarding any prior sanctions or unpaid balances. If any question is answered ‘Yes’, ensure to complete the necessary supplementary forms.
12. Sign and date the form in the Signature and Affirmation section. Print your name and provide a contact number for the person who prepared the application. Ensure that you use an original signature and not a stamp.
13. After filling out the form, review all entries for accuracy. Save your changes, download or print your completed form for your records.

Complete your NY EMEDNY-436901 enrollment form online today to ensure your participation in the Medicaid Program.