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Emedny 436701 2014 form

Emedny 436701 2014 form-2025

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The document is a New York State Medicaid Enrollment Form for providers wishing to enroll in the Medicaid Program. It outlines the requirements for enrollment, including compliance with state regulations, the necessity of providing personal and business information, and the implications of rendering services before completing enrollment. The form also includes sections for disclosing ownership and control interests, managing employees, and answering questions related to past sanctions or ownership changes. Providers must sign the form to affirm their understanding of the rules and regulations governing Medicaid participation.

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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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