Emedny 436901 2026

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119 votes

The document is a New York State Medicaid Enrollment Form for practitioners seeking to enroll as non-billing providers (ordering, referring, attending, or prescribing). It outlines the compliance requirements with state regulations, the necessity of providing personal information for enrollment, and instructions for submitting the form. The document emphasizes that those who will bill Medicaid should use a different form and includes sections for disclosing ownership and control interests, as well as questions regarding prior conduct related to Medicaid participation.

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Click ‘Get Form’ to open the emedny 436901 in the editor.
Begin by filling out the 'Category(s) of Service' section with the appropriate 4-digit codes as provided in the instructions.
Indicate whether this is a New Enrollment, Reinstatement, or Revalidation by checking the corresponding box.
Enter your full name as it appears on your license, along with your Date of Birth and Social Security Number (SSN).
Provide your email address, NPI (National Provider Identifier), specialty, and license number. Ensure all information is accurate.
Complete both the Correspondence Address and Service Address sections. Remember that PO Boxes are not acceptable for these fields.
Fill out the Disclosure of Ownership and Control sections carefully, ensuring you include all required details about ownership interests.
Respond to all questions in Section 6 regarding any prior conduct or sanctions related to Medicaid programs.
Finally, sign and date the form in the Signature and Affirmation section before submitting it through our platform.

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Versions	Form popularity	Fillable & printable
2020	4.9 Satisfied (28 Votes)
2019	4.3 Satisfied (24 Votes)
2015	4.3 Satisfied (119 Votes)
2014	4.2 Satisfied (69 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I contact NYS Medicaid?

For questions regarding your eligibility or to find out which managed care plan you are enrolled in, you may call the Medicaid Helpline at 1-800-541-2831. It is available from 8:00 a.m. through 8:00 p.m., Monday through Friday and from 9:00 a.m. to 1:00 p.m., on Saturday.

How do I contact Medicare NY?

Call us at 1-800-MEDICARE (1-800-633-4227). Help from Medicare is available 24 hours a day, 7 days a week, except some federal holidays. TTY users can call 1-877-486-2048.

How do I contact Medicaid Choice in NY?

You can also call us, New York Medicaid Choice, if you need help. You can call us at 1-888- 401-6582 (TTY: 1-888-329-1541).

How long does it take to get approved for Medicaid in New York?

ALL DOCUMENTS PERTAINING TO ELECTRONIC REMITTANCE CAN BE FOUND AT .EMEDNY.ORG OR BY CALLING THE EMEDNY CALL CENTER AT: 1-800-343-9000. Certification Statements remain in effect and apply to all claims until superseded by another properly executed Certification Statement.

What is the phone number for Medicaid New York EDI?

All Medicaid recipients are assigned a unique CIN even if they are enrolled in a Medicaid managed care (MMC) plan. The CIN is located on all member cards including MMC plan cards. On some MMC cards its called CIN however other MMC cards may identify it as Program ID, Member ID, or ID#.

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How do I contact NY Medicaid?

Call the HRA Medicaid Helpline at 1-888-692-6116 for more information or visit a Medicaid Office to apply.

How do I check the status of my Medicaid?

Log into your states Medicaid portal Many states have online portals where you can check your Medicaid coverage status. If you already created an account when you applied, log in to see any updates or changes to your status. Look for a section that shows your coverage details or current eligibility.