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Click ‘Get Form’ to open the emedny 436701 in the editor.
Begin by selecting your provider type: either 'Billing Provider' or 'Managed Care Only'.
Indicate your enrollment status by checking the appropriate box for New Enrollment, Revalidation, Change of Ownership, or Reinstatement.
Fill in your Applicant/Business Name exactly as it appears on your license. Include your NPI and FEIN numbers.
Complete the Correspondence section with the address where letters and claims should be sent. Ensure all fields are filled accurately.
In the Disclosure of Ownership and Control section, provide details about ownership interests and any related individuals as required.
Answer all questions in Section 6 regarding any past sanctions or ownership changes, ensuring clarity and accuracy.
Finally, sign and date the form at the end to affirm your compliance with Medicaid regulations.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (135 Votes)
2015	4.4 Satisfied (45 Votes)
2014	4 Satisfied (29 Votes)

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What is credentialing with Medicaid?

Credentialing is the process of verifying a healthcare providers qualifications, licensure, and compliance with CMS standards. Both Medicare and Medicaid require this step to ensure that providers meet regulatory and quality-of-care standards before they can bill for services.

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 do I find my Medicaid ID number in NY?

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#.