Fillable New York State Medicaid Disclosure Form

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New York State Medicaid Disclosure Form

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EMEDNY-380104 (10/20)
1
New York State Medicaid
Disclosure Form
Thank you for updating your provider records with the Medicaid Program. As a Medicaid
provider, you
have
agreed to comply with the rules, regulations and official directives of
the NYS
Department
of Health including, but not limited to, Part 504 of
18 NYCRR (i.e., Title 18). Title 18 can be found by choosing the Laws and Regulations link of
the Department of Health’s website, www.health.ny.gov.
This form must be completed when you experience a change in managing employee(s)
or a change in those with a control interest.
New York State’s Personal Privacy Protection
Law requires us to inform every person from
whom we request personal information why we are requesting information and how we will
use it. The information requested will permit proper payments to you as a Medicaid
provider, according to the provisions of applicable State and Federal Law and Regulations.
Collection of this information is authorized by Section 367-b of the Social Services Law.
This information will be used as one element of various reviews before payment is made for
the goods or services
furnished and/or for any post payment audits required by the State or
Federal authorities. This information will also be used to satisfy the reporting requirement
imposed upon us by State and Federal Regulations (e.g., by IRS for payment information
reporting purposes). Failure to provide us with the information will prevent establishing the
records necessary to enroll you as a Medicaid provider. The information will be maintained
by the New York State Department of Health, Office of Health Insurance Pro
grams, Division
of OHIP Operations,
Bureau of Provider Enrollment, Albany New York.
NOTE: Refer back to this page when identifying managing employees and those with a control
interest:
EMEDNY-380104 (10/20)
2
NY MEDICAID
DISCLOSURE FORM
for
PRACTITIONERS or PHYSICIANS
(Groups Must Use Form EMEDNY
-380102)
Mail to:
eMedNY
PO Box 4610
Rensselaer, NY 12144
Effective Date of Change:
SSN:
Provider Name
NY Medicaid ID
(if known):
Completion is required
by 18NYCRR, Section 502.
5(b) Failure to provide the information requested
may impact your enrollment
. Visit
www.health.ny.gov to rev iew definitions and policy found at 18NYCRR, Section 504.1 before completing this form. .
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.
Name
Association Type (see page 1)
Home Address
City & State
Zip Code (9 digit)
SSN
Date of Birth
Familial Relationship
Name
Association Type (see page 1)
Home Address
City & State
Zip Code (9 digit)
SSN
Date of Birth
Familial Relationship
Name
Association Type (see page 1)
Home Address
City & State
Zip Code (9 digit)
SSN
Date of Birth
Familial Relationship
Name
Association Type (see page 1)
Home Address
City & State
Zip Code (9 digit)
SSN
Date of Birth
Familial Relationship
{This page may be copied for additional listings}
Respond to these questions on behalf of the Provider, the Owners,
and Managing Employees and those with a
Control Interest:
1. Have any of these individuals/entities 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 these individuals/entities 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 in any State?
Yes
No
EMEDNY-380104 (10/20)
3
3. Have any of these individuals/entities 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
se
individuals/entities ?
Yes
No
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.
5. Does the Provider have any unpaid balances owed to the NY Medicaid Program related to this
Business or another entity owned by the Applicant?
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
By signing this form, the Provider understands and agrees to the following:
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 18NYCRR which can be found at the Department of Health’s website,
www.health.ny.gov
In addition, pursuant to 42 CFR, Part 455.105, by enrolling in the Medicaid Program you agree to disclose the
following regarding business transactions within the next 35 days upon request of the Department or the Secretary
of Health and Human Services.
(1) Information about the ownership of any subcontractor with whom the provider has had business
transactions totaling more than $25,000 during the 12-month period ending on the date of the request, and
(2) Any significant business transactions between the provider and any wholly owned supplier, or between
the provider and any subcontractor during the 5-year period ending on the date of the request.
As a Medicaid Provider you agree to abide by all applicable Federal and State laws as well as the rules and
regulations of other New York State agencies particular to the type of program covered by this enrollment
application.
For those providers for whom the Mandatory Compliance Law applies
(https://omig.ny.gov/compliance/compliance
), the Provider has certified via the CERTIFICATION STATEMENT
FOR PROVIDER BILLING MEDICAID that the provider adopted, and i
mplemented, where applicable, an
effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied
the requirements of Title 18 of the New York Code, Rules and Regulations, Part 521.
Unannounced site visits by
Medicaid, CMS or their agents/designated contractors may be a condition of initi
al
and continued enrollment. In addition, the provider and/or owners (defined as at least a 5 % interest) may be
required to consent to criminal background checks including fingerprinting.
As a Medicaid Provider you agree to notify this Department immediately of any changes supplied in this
disclosure document as well as impending ownership changes or any other changes.
The Department may deny or terminate enrollment as a provider in the Medicaid program if it is determined that
executive compensation, bonuses, incentiv
es and costs of administration exceed reasonable levels.
WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR
REPRESENTATION ON THIS STATEMENT MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS.
IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION
REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY
PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR SECRETARY,
AS APPROPRIATE.
__________________________________________________ __________________________________
Provider’s Signature (original; no stamps) Date
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New York State Medicaid Disclosure Form

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Completed 2 August 2021

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