Ny medicaid form: Fill out & sign online

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Click ‘Get Form’ to open the NY Medicaid Enrollment Form in our platform.
Begin by entering your personal information in the Applicant Name section, ensuring it matches your license. Include your Date of Birth and SSN.
Provide your email address and NPI number. Select the appropriate Category of Service by checking the relevant box for New Enrollment, Reinstatement, or Revalidation.
Fill out the Correspondence Address and Service Address sections accurately. Remember, PO Boxes are not acceptable for these fields.
Complete the Disclosure of Ownership and Control section, providing all required details about ownership interests and relationships.
Answer all questions in Section 6 regarding any past sanctions or unpaid balances. Ensure you provide truthful responses as this is crucial for your application.
Finally, sign and date the form in the Signature and Affirmation section before submitting it through our platform.

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