NOTE: All questions must be answered.
If you answered “Yes” to any of the questions above, you must complete
and submit the “Prior Conduct Questionnaire” available at
www.emedny.org.
Please continue and Answer Question 5.
SECTION 5:
Managing Employees, Agents, & Those with a Control Interest - Including, but not necessarily limited to, the
following: Compliance Officer, all Managing Employees (includes Employee/Lifestyle Coach(s), general, business and office
managers; all persons who exercise operational or managerial control of a provider; all persons who directly or indirectly
conduct the day-to-day operations of a provider). Include familial relationship to the Provider (spouse, parent, child, sibling), if
any. {If additional space is needed, copy form; all entries must be on the form}
Completion of all fields is required by 42 CFR Part 455.104. Failure to provide the information requested will cause the
application to be returned. Click here
to review definitions and policy found at 18NYCRR, Section 504.1. If additional space
is needed, copy form; all entries must be on the form.
Association Type (see instructions)
Association Type (see instructions)
Association Type (see instructions)
SECTION 6:
Respond to these questions on behalf of: 1. the Applicant
2.
all individuals and entities identified in Sections 1 & 5
3.
any entity in which the Applicant has a 5% or more ownership
1.
Have any of the individuals/entities (1, 2 and 3) been terminated, denied enrollment, suspended, restricted by
Agreement or otherwise sanctioned by the Medicaid Program in New York or in any other State, Medicare, or
any other governmental or private medical insurance program?
Yes No
2.
Have any of the individuals/entities (1, 2 and 3) ever been convicted of a crime related to the furnishing of, or
billing for, medical care or supplies or which is considered an offense involving theft or fraud or an offense
against public administration or against public health and morals?
Yes No
3.
Have any of the individuals/entities (1, 2 and 3) ever had their business or professional license or certification,
or the license of an entity in which they had an ownership interest over 5% ever been revoked, suspended,
surrendered, or in any way restricted by probation or agreement by any licensing authority in any State?
Yes No
4.
Is there currently pending any proceedings that could result in the above stated sanctions for the individuals/
entities (1, 2 and 3)?
Yes No
5.
Do you, including any entity in which you have ownership, have any unpaid balances owed to the NY
Medicaid Program?
Yes No If yes, indicate amount $
If yes, has payment been arranged? Yes No If yes, attach verification of arrangement.
If no, this enrollment will be reviewed by the OMIG