Emedny form 426601 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Group Member’s Name in the designated field. Ensure that you provide your full legal name as it appears on official documents.
3. Next, input your National Provider Identifier (NPI). This is essential for enrollment and participation in the Medicaid program.
4. Fill in your Medicaid number, which is required for processing claims.
5. In the following section, enter the Name of your Group. This should reflect the official name under which your group operates.
6. List all Service Address(es) where you work as a group member. Be sure to exclude any private practice addresses and provide accurate locations.
7. Finally, review the agreement statement and print your full name, sign, and date the form at the bottom to confirm your participation.

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