424402 2026

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4.4 out of 5

49 votes

The document provides detailed instructions for completing the New York Medicaid enrollment form for transportation providers. It outlines general and additional requirements, including necessary documentation, service categories, and compliance certifications. The instructions emphasize the importance of completing all fields accurately to avoid delays in enrollment and highlight specific licensing requirements based on the type of transportation service offered.

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Click ‘Get Form’ to open the 424402 document in the editor.
Begin by completing all required fields. Ensure you type or print legibly in black or blue ink, avoiding red ink and white-out.
In the 'Category of Service' section, enter the appropriate 4-digit code for your service type (e.g., 0602 for Ambulette). Check the corresponding box for New Enrollment, Revalidation, or Reinstatement as applicable.
Fill in the 'Association Types' by entering the letter that corresponds to your role (B, F, H, M, P, or U).
Attach all required documents listed in the instructions. Make sure they are legible and on standard paper size.
Complete the signature field with an original signature and date it appropriately before submitting.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (36 Votes)
2015	4.4 Satisfied (49 Votes)

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