Fillable New York State Medicaid Enrollment Form

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New York State Medicaid Enrollment Form

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EMEDNY-436801 (10/20)
1
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 Programs, Division
of OHIP Operations, Bureau of Provider Enrollment, Albany, New York.
New York State Medicaid
Enrollment Form
Thank 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 (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.
You will be at financial risk if you render services to Medicaid beneficiaries before
successfully completing the enrollment process. Payment will not be made for any
claims submitted for services, care, or supplies furnished before the enrollment date
authorized by the Department of Health. If you have any questions, contact the
eMedNY Call Center at (800) 343-9000.
Consider printing the
Instructions to Complete Enrollment Form
before
continuing. Please complete pages 2 through 6; form must be completed in its
entirety.
EMEDNY-436801 (10/20)
2
NY MEDICAID PROVIDER ENROLLMENT FORM
for
PRACTITIONERS
Mail to:
eMedNY
PO Box 4603
Rensselaer, NY 12144-4603
Category(s) of Service
:
Enter the 4-digit code(s) given in the instructions: __
New Enrollment
(not currently enrolled)
Reinstatement/Reactivation
If Applicant was previously
excluded/terminated from the Medicaid
Program, complete the Prior Conduct
Questionnaire found at
www.eMedNY.org and include it with this
Enrollment Form
Applicant Name (exactly as it appears on your license/registration) Last, First, MI
NPI (Individual) –
if incorporated, completion of a Group application is also necessary.
SSN
License #
State of Licensure if not New York
Limited License?
Yes
No
Applicant’s e
-Mail Address
-
REQUIRED
:
Are you enrolled in Medicare?
Yes
No
DEA Number (if required)
DEA Effective Date (MM/DD/YYYY)
DEA Expiration Date (MM/DD/YYYY)
If affiliated with a Group, do you
have a Private Practice as well?
Yes
No
N/A
If member of a group or organization:
Group/Org Name:
If member of a group or
organization:
Group/Org NPI:
CORRESPONDENCE: (indicate where letters and claims forms, if any, should be sent) – PO Box not acceptable
Attention:
Street Address
Suite / Department/ Floor
City
State
Zip Code (9 digit)
County (if in New York)
Telephone Number (w/ extension)
Fax Number
PAY TO ADDRESS: (indicate where checks & remittance statements should be sent until EFT and e-Remits are in place):
Attention:
Street Address or PO Box
Suite / Department/ Floor
City
State
Zip Code (9 digit)
County (if in New York)
Telephone Number (w/ extension)
Fax Number
CORPORATE ADDRESS: (indicate where Annual Tax Documents (Form 1099) should be sent)
Attention:
Street Address or PO Box
Suite / Department/ Floor
City
State
Zip Code (9 digit)
County (if in New York)
Telephone Number (w/ extension)
e-Mail Address - REQUIRED
EMEDNY-436801 (10/20)
3
{
If additional space is needed, copy form; all entries must be on the form}
SERVICE ADDRESS: (where service is provided) – DO NOT LIST A PATIENT’S ADDRESS
(see instructions)
*Valid Telephone numbers are required for each service address.
Attention:
Street Address
(PO Box is not acceptable)
Suite / Department / Floor
City
State
Zip Code (9 digit)
County (if in New York)
*Telephone Number (w/ extension)
Fax Number
Type of Practice (Check One)
Individual (1)
Group (2)
Place of Service (Check One)
Pri vate Office (1) Freestanding Clinic (3)
Hospital/Nursing Home (2)
SERVICE ADDRESS
: (where service is provided)
– DO NOT LIST A PATIENT’S
ADDRESS
(see instructions)
*Valid Telephone numbers are required for each service address.
Attention:
Street Address
(PO Box is not acceptable)
Suite / Department / Floor
City
State
Zip Code (9 digit)
County (if in New York)
*Telephone Number (w/ extension)
Fax Number
Type of Practice (Check One)
Individual (1)
Group (2)
Place of Service (Check One)
Pri vate Office (1) Freestanding Clinic (3)
Hospital/Nursing Home (2)
SERVICE ADDRESS: (where service is provided) – DO NOT LIST A PATIENT’S
ADDRESS
(see instructions) *Valid Telephone numbers are required for each service address.
Attention:
Street Address
(PO Box is not acceptable)
Suite / Department / Floor
City
State
Zip Code (9 digit)
County (if in New York)
*Telephone Number (w/ extension)
Fax Number
Type of Practice (Check One)
Individual (1)
Group (2)
Place of Service (Check One)
Pri vate Office (1) Freestanding Clinic (3)
Hospital/Nursing Home (2)
SERVICE ADDRESS: (where service is provided) – DO NOT LIST A PATIENT’S ADDRESS
(see instructions)
*Valid Telephone numbers are required for each service address.
Attention:
Street Address
(PO Box is not acceptable)
Suite / Department / Floor
City
State
Zip Code (9 digit)
County (if in New York)
*Telephone Number (w/ extension)
Fax Number
Type of Practice (Check One)
Individual (1)
Group (2)
Place of Service (Check One)
Pri vate Office (1) Freestanding Clinic (3)
Hospital/Nursing Home (2)
EMEDNY-436801 (10/20)
4
DISCLOSURE OF OWNERSHIP AND CONTROL
Completion 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 before completing this form. {If additional space is
needed, copy form; all entries must be on the form}.
SECTION 1:
Disclosing Entity / Applicant
(Individual named on page 2 of this application)
Name
NPI
Home Address (Street)
City & State
Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
Ownership in Applicant
(if required by 18NYCRR, Section 504.1(d)(18)(iv)). Include familial relationship to the
Applicant and other Owners (spouse, parent, child, sibling), if any. The address for corporate entities must include every
business address. See 42 CFR Part 455.104(b)(1)(i) for more information).
Name of Individual or Entity
% of Ownership
NPI
Address (Home Address
if individual)
City & State
Zip Code (9 digit)
SSN (if individual)
FEIN (if entity)
Date of Birth (if individual)
(MM/DD/YYYY)
Familial Relationship (if individual,
if any)
SECTION 2
:
Ownership in Other Disclosing Entities(ODE)
(per 42 CFR, Part
455.104(a)(3)) - (Complete if any identified
in Section 1 has an ownership or control interest in ODE)
Name (from Section 1)
Name of ODE
NPI or Medicaid ID of ODE
Name (from Section 1)
Name of ODE
NPI or Medicaid ID of ODE
SECTION 3:
Ownership in Subcontractors
If the Applicant has an ownership or control interest of 5% or more in a
subcontractor and an Owner of the Applicant also has an ownership or control interest in the subcontractor, complete the
boxes below. If those identified in this Section have a familial relationship with a person with ownership or control interest in
one of these subcontractors, complete Section 4).
Owner’s Name (from Section 1)
Subcontractor Name
Tax Identification Number
Owner’s Name (from Section 1)
Subcontractor Name
Tax Identification Number
SECTION 4:
Familial Relationship in Subcontractors
(Complete if those identified in Section 3 have a *familial relationship
with a person with ownership or control interest in one of the subcontractors identified in Section 3).
*parent, child, sibling, spouse
Owner’s Name (from Section 1)
Subcontractor’s Name
Name & Familial Relationship
Owner’s Name (from Section 1)
Subcontractor’s Name
Name & Familial Relationship
EMEDNY-436801 (10/20)
5
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.
Name
Association Type (see instructions)
Home Address
City & State
Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
Familial Relationship
Name
Association Type (see instructions)
Home Address
City & State
Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
Familial Relationship
Name
Association Type (see instructions)
Home Address
City & State
Zip Code (9 digit)
SSN
Date of Birth (MM/DD/YYYY)
Familial Relationship
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 in
volving theft or fraud or an offense
against public administration or against public health and morals in any State?
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
EMEDNY-436801 (10/20)
6
SIGNATURE AND AFFIRMATION
By signing this enrollment form for participation in the New York State Medicaid Program, the Applicant/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 s
ubcontractor 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 betw
een
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 implemented, 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 initial
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
enrollment agreement,
including impending ownership
changes.
The Department may deny or terminate enrollment as a provider in the Medicaid program if it is determined that
executive compensation, bonuses, incentives 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.
Applicant / Provider’s Signature (original; no stamps) Date
(MM/DD/YYYY)
_ _
Name & Telephone Number of Person who Prepared Application
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New York State Medicaid Enrollment Form

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Completed 20 November 2020

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