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Click ‘Get Form’ to open the emedny 520101 in the editor.
Begin by selecting the appropriate box for your provider type: either Licensed Home Care Services Agency (LHCSA) or Independently Enrolled Nurse. Fill in your agency name, NYS license number, and Medicaid Provider Identification Number.
For LHCSA providers, certify that the nurses providing services are trained and experienced in caring for medically fragile pediatric patients. Ensure you maintain documentation for inspection.
If you are an independently enrolled nurse, provide your name, NYS license number, and specify your training details along with completion dates. Include any relevant skills such as tracheostomy care or home infusion.
Sign and date the form at the bottom to confirm your certification of training and experience before submitting it through eMedNY.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (163 Votes)
2020	4.4 Satisfied (170 Votes)
2016	4.2 Satisfied (130 Votes)
2010	4 Satisfied (56 Votes)

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How do I contact Medicaid provider enrollment in NY?

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email.

What is eMedNY eXchange?

eMedNY eXchange is an access method used to submit HIPAA-compliant transactions to the eMedNY system via a web-based application.

How much is the medicare application fee?

The 2025 enrollment application fee is $730. Whether you apply for Medicare enrollment online or use the paper application, you can pay the Medicare application fee online through: PECOS: During the application process, PECOS prompts you to pay the application fee.

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What is ePACES NY Medicaid?

ePACES is the acronym for the Electronic Provider Assisted Claim Entry System, a web-based application which will allow Providers to create/submit claims and other transactions in HIPAA format. eMedNY developed this application on behalf of the NYS Department of Health.

Emedny 520101 2026

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