Fillable New York State Medicaid Enrollment Form

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New York State Medicaid Enrollment Form

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EMEDNY-436701 (10/20)
1
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 ri
sk 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 8; form must be completed in its
entirety.
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
provi
der, 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 Hea
lth, Office of Health Insurance Programs, Division
of OHIP Operations, Bureau of Provider Enrollment, Albany, New York.
EMEDNY-436701 (10/20)
2
NY MEDICAID PROVIDER ENROLLMENT FORM
for
BUSINESSES
Only Choose One:
Billing Provider
Managed Care Only (Non Billing)
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)
Revalidation
(enrolled; required to revalidate)
Change of Ownership
(enrolled, complying with 42CFR Part 455.104)
NY Provider ID # ___________
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 / Business Name (exactly as it appears on your license/registration; if none use name from IRS assignment letter)
FEIN
License #
State of Licensure if not New York
License Begin Date (MM/DD/YY
YY)
Doing Business as (DBA) Name
DEA Number (Pharmacy Only)
DEA Effective Date (MM/DD/YYYY)
DEA Expiration Date (MM/DD/YYYY)
Are you enrolled
in Medicare? Yes No
Applicant’s e-Mail Address - REQUIRED
Ownership Code: 69-Federal 70-County 71-Municipal 72-State 73-Voluntary / Not-for-Profit
74-For Profit Corp. 75-For Profit Partnership 76-For Profit-Individual 19-Other
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-436701 (10/20)
3
PLEASE NOTE:
Services rendered to Medicaid patients at your service address may not be billed through any
other provider number. If you provide services at your service location that are subsequently
billed through another provider number (including a provider number
issued to another location
under the same ownership) your application will be denied and action will be taken against the
billing provider.
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
If the Applicant is a Pharmacy, Laboratory or a Portable X-Ray provider, please provide the
Name and NPI of the Supervising Pharmacist, Laboratory Director or
Supervising Physician,
respectively.
PLEASE NOTE: If this individual is not actively enrolled in the NY Medicaid Program, s/he
must complete the appropriate enrollment form found at www.eMedNY.org.
Name:
NPI:
EMEDNY-436701 (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
(Entity named on page 2 of this application)
Entity Name
FEIN
NPI (if exempt, leave blank)
Ownership in Applicant
(per 42 CFR, Part 455.104(b)(1)(i)
–
(Entities and/or Individuals) Copy this page to report
additional owners.
Name of Individual or Entity
Title (if individual)
Date of Birth (if individual)
(MM/DD/YYYY)
Address (Home Address if Individual; Primary Address if Corporation) – Street
City, State & Zip Code (9 digit)
SSN (for individual)
FEIN (for entity)
% of Ownership (if none, put 0%)
NPI or NY Medicaid ID (if none, write None)
For Individuals Only: If you are related* to another person with an ownership or control interest in the Applicant, complete the following:
Name of other Owner: Relationship to other Owner (parent, child, sibling, spouse):
____________________ _____________________
____________________ _____________________
____________________ _____________________
For Corpo rations & Optical Establishments Only: Use the space below to report other business addresses (per 42CFR, Part 455.104(b)(1)(i)):
1)
____________________
2)
_____________________
3)
______________________
_____________________ ______________________ _______________________
_____________________ ______________________ _______________________
Name of Individual or Entity
Title (if individual)
Date of Birth (if individual)
(MM/DD/YYYY)
Address (
Home Address if Individual; Primary Address if Corporation)
- Street
City, State & Zip Code (9 digit)
SSN (for individual)
FEIN (for entity)
% of Ownership (if none, put 0%)
NPI or NY Medicaid ID (if none, write None)
For Individuals Only
: If you are related* to another person with an ownership or control interest in the Applicant, complete the following:
Name of other Owner: Relationship to other Owner (parent, child, sibling, spouse):
____________________ _____________________
____________________ _____________________
____________________ _____________________
For Corpo rations & Optical Establishments Only: Use the space below to report other business addresses (per 42CFR, Part 455.104(b)(1)(i)):
1)
____________________
2)
_____________________
3)
______________________
_____________________ ______________________ _______________________
_____________________ ______________________ _______________________
EMEDNY-436701 (10/20)
5
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
Subcontractor’s Name
Name & Familial Relationship
Owner’s Name
Subcontractor’s Name
Name & Familial Relationship
SECTION 5:
Agents,
Managing Employees
& Those with a Control Interest
– Including, but not necessarily
limited to, the following: Facility Administrator, all Members of the Board of Directors, Managing Employees, Compliance
Officer, Laboratory Director, Supervising Pharmacist, Employee/Lifestyle Coach
(although unusual, if None, indicate NONE in the
first "Name" field below)
. Include familial relationship to the Applicant (spouse, parent, child, sibling
),
if any.
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
EMEDNY-436701 (10/20)
6
{
If additional space is needed, copy form; all entries must be on the form
}
Agents, Managing Employees
& Those with a Control Interest
– (continued)
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
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
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
EMEDNY-436701 (10/20)
7
SECTION 6:
Respond to these questions on behalf of: 1. the Applicant
2. all individuals and entities identified in Section
s 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 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
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 Questions 5 through 7.
5. Has there been a change of ownership or control within the last 12 months to any of the entities (1, 2 and 3)?
Yes
No
If “Yes”, provide:
NY Medicaid ID or NPI ____________
Date of Ownership Change
_______________ (MM/DD/YYYY)
6. Do you anticipate a change of ownership within the next 12 months to any of the above entities (1, 2 and 3)?
Yes
No
If “Yes”, when do you anticipate the ownership change will occur: ___________ (MM/DD/YYYY)
7. Does the Applicant/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
EMEDNY-436701 (10/20)
8
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 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 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 Yor
k 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 Depa
rtment 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 31 October 2021

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