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Click ‘Get Form’ to open the NY State Medicaid Enrollment Form in our platform.
Begin by filling out your personal information in the 'Applicant Name' section, ensuring it matches your license. Include your Date of Birth and SSN.
Indicate whether you are enrolled in Medicare and provide your NPI numbers. If applicable, specify if you have a Private Practice.
Complete the 'Contact Address' and 'Correspondence Address' sections accurately, as these will be used for communication regarding your application.
In the 'Disclosure of Ownership and Control' section, provide detailed information about ownership interests and any familial relationships as required.
Answer all questions in the 'Agents and Managing Employees' section truthfully, including any relevant familial relationships.
Finally, review all entries for accuracy before signing the form electronically within our editor. Ensure that you date your signature appropriately.

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2014	4.9 Satisfied (490 Votes)

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