Emedny 436601 2025

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The document is the New York State Medicaid Enrollment Form, which outlines the process and requirements for providers to enroll in the Medicaid program. It emphasizes compliance with state regulations, the importance of completing the enrollment before providing services, and details about personal information collection for payment processing. The form includes sections for applicant information, ownership disclosure, managing employees, and questions regarding prior conduct. It also highlights the legal obligations of providers and consequences for false statements.

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