Emedny 436801 2026

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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 potential financial risks of rendering services before completing enrollment. The form also includes sections for disclosing ownership and control interests, as well as questions regarding prior conduct related to Medicaid or other insurance programs. Providers must sign the form to affirm their understanding and agreement to comply with all applicable laws and regulations.

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Click ‘Get Form’ to open the emedny 436801 in the editor.
Begin by entering your Category(s) of Service using the provided 4-digit code(s). Indicate whether this is a New Enrollment, Reinstatement/Reactivation, or Revalidation.
Fill in your Applicant Name exactly as it appears on your license. Include your NPI, License Number, and State of Licensure if not New York.
Provide your SSN and email address. If applicable, include your DEA Number and indicate if you are affiliated with a Group or have a Private Practice.
Complete the Correspondence section with the appropriate mailing address for letters and claims forms. Ensure that no PO Box is used.
In the Disclosure of Ownership and Control section, provide all required information about ownership interests and managing employees as specified.
Answer all questions in Section 6 regarding any past sanctions or unpaid balances related to Medicaid. Attach any necessary documentation if you answered 'Yes' to any questions.
Finally, sign and date the form in the Signature and Affirmation section to confirm your understanding of compliance requirements.

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What is eMedNY eXchange?

0:20 2:56 Application specific to your provider. Type this application is usually available on the statesMoreApplication specific to your provider. Type this application is usually available on the states Medicaid. Website such as the New York State Department of Health. Website.

How to check New York state Medicaid status?

eMedNY eXchange is an access method used to submit HIPAA-compliant transactions to the eMedNY system via a web-based application.

How to get Medicaid provider ID?

All Medicaid recipients are assigned a unique CIN even if they are enrolled in a Medicaid managed care (MMC) plan. The CIN is located on all member cards including MMC plan cards. On some MMC cards its called CIN however other MMC cards may identify it as Program ID, Member ID, or ID#.

Emedny 436801 2026

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