EMEDNY-401103 (11/16)
DEFAULT ETIN SELECTION FORM
eMedNY uses a Default Electronic Transmitter Identification Number (ETIN), linked to your MMIS
Provider Number/NPI, for reporting the following types of claims on your electronic or PDF remittance:
• claims submitted on paper forms
• State submitted adjustments/voids
• automated Medicare crossover claims
You must select a default to identify where remittances for these types of claims are to be routed.
NOTE:
The ETIN you select as the Default must be set to receive electronic or PDF remittances, prior to
submitting this form. If you need to request electronic or PDF remittances, you must submit the
ELECTRONIC OR PDF REMITTANCE ADVICE REQUEST FORM located at
www.emedny.org. Look under
Provider Enrollment and Provider Maintenance Forms or click the “Go Green” icon on the homepage. At
the same time, you can also use the ELECTRONIC OR PDF REMITTANCE ADVICE REQUEST FORM to select
a Default ETIN.
To select or change a Default ETIN, place an “X” in the appropriate box below and indicate the Default
ETIN in the space provided. Check the ‘Select Default’ box if there is currently
no Default ETIN listed on
the provider’s file. Check the ‘Change Default’ box to change the Default ETIN currently listed on the
provider’s file. If you have multiple ETINs, set to receive electronic or PDF remittance, you may only
choose
one
Select Default Change Default
as the Default.
Default ETIN: _______________________
NPI (unless NPI exempt):_______________________ (must be linked to the Default ETIN listed above)
MMIS Provider Number: ______________________ (must be linked to the Default ETIN listed above)
(If NPI exempt)
SIGNATURE: _____________________________________ DATE SIGNED: ______________________
For Practitioners, the Practitioner must sign this form.
S
IGNED BY (PRINT NAME): __________________________ TITLE: ____________________________
EM
AIL ADDRESS: _____________________________ PHONE #: _______________________________
Please mail or fax this completed form to:
eMedNY
Attn: Provider Enrollment Support
P.O. Box 4614
Rensselaer, New York 12144
FAX: (518) 257-4632
Q
uestions about this form should be directed to the eMedNY Call Center at (800) 343-9000.
