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432301 2026
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- Click ‘Get Form’ to open the 432301 document in the editor.
- Begin with Section One, where you will enter the Nurse’s Name, NYS License Number, Medicaid Provider Identification Number (if applicable), and National Provider Identifier (NPI). Ensure all information is accurate as it is crucial for reimbursement.
- In Section One, certify your training and experience by signing the form. This certification is essential for receiving the enhanced Medicaid reimbursement rate.
- Proceed to Section Two if you wish to enroll in the PDN Provider Directory. Fill in your contact email address and phone number, ensuring they are correct for future communications.
- Sign Section Two to confirm your participation in the directory. This step is vital as it indicates your willingness to accept inquiries for providing care.
- Once completed, submit the form through eMedNY as instructed at the end of the document.
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