hank you for your interest in enrolling with the New York State Medicaid Program. As
a Medicaid provider, you agree to comply with the rules, regulations and official directives of
the Department, including, but not limited to Part 504 of 18 NYCRR which can be found at
the Department of Health’s website, www.health.ny.gov.
This enrollment form should be used by practitioners seeking enrollment as:
- An ordering referring, attending or prescribing practitioner (attending providers
should use this form if their name and NPI will only appear on the hospital’s claim).
These providers will not submit claims to Medicaid and, therefore will not receive
payment from the Medicaid Program or, - A Medicaid Managed Care Network provider.
If you will also provide medical services to patients, or as an attending provider will submit a
separate claim to Medicaid for your service, do not complete this form. Visit
www.eMedNY.org and complete the enrollment form appropriate for your license/certification.
Consider printing the Instructions to Complete Enrollment Form before
continuing. Please complete pages 2 through 5; form must be completed in its
entirety.