How To Apply For Lpn Medicaid Number

General Instructions for the Enrollment Form

Complete ALL items on the form unless otherwise instructed below. Failure to complete all required fields will result in your enrollment form being returned to you which may have an impact on the enrollment effective date.
Required documents MUST cover the application date and be continuous through the current date.
Completion of signature field is required and must be original. Initials or rubber stamped signatures will not be accepted.
Type or legibly print in black or blue ink. Do not use red ink, nor white-out. All attachments will be scanned so they must be legible and on standard 8.5 x 11 paper in good condition.
Keep a copy of all documents submitted.
Valid Telephone numbers are required for each service address.

Additional Instructions for the Enrollment Form

Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form
0521 - Licensed Practical Nurse, OR
0522 - Registered Nurse

Choose ONE Application Type and check the corresponding box on the Enrollment Form:

Check New Enrollment if the NPI or Provider listed is not currently enrolled in NYS Medicaid
Check Revalidation if the NPI or Provider is currently enrolled and you were notified that Revalidation is required per 42 CFR, Part 455.414. The Provider ID can be found on the Revalidation Letter you received
Check Reinstatement/Reactivation if the provider was previously enrolled but is not currently active.
Please note: You will be at financial risk if you render services to Medicaid beneficiaries before successfully completing the enrollment process.

DEA Number & Dates: Leave Blank

Service Address: Enter your home address

Type of Practice: Leave Blank

Place of Service: Leave Blank

Association Types: Enter the letter (B, F, H, I, M, P or U) which best corresponds to the individual's role: Note: ALL lifestyle coaches providing NDPP services for your organization must be listed in Section 5 of the application as a I-Employee/Lifestyle Coach

B: Board of Directors Member		F: Facility Administrator		H: Compliance Officer		I: Employee/Lifestyle Coach
M: Managing Employee		P: Supervising Pharmacist		U: Laboratory Director

Requirements & Additional Forms

Proof of current license / registration Examples: 1) Copy of license with future expiration date, 2) Copy of license registration/renewal, or 3) Printout of your license status from the licensing agency's website.

Electronic Funds Transfer (EFT) Authorization - form #701101 (NOT REQUIRED for revalidation if EFT is already in place and no change is requested). If you answered "No" to the Enrollment Form's Group question (Line 4 of page 2), EMEDNY -701101 is NOT required. Also not required for revalidation or reinstatement/reactivation
ETIN Certification Statement for New Enrollments - form #490602 (NOT REQUIRED for revalidation, reinstatement, reactivation, or if you are enrolling as a Managed Care Only non-billing provider). If you already have an existing ETIN that you wish to affiliate with, submit the Certification Statement for Existing ETINs (EMEDNY 490601) after you receive your Provider ID. This form is available here.
Prior Conduct Questionnaire - form #431001 (If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form).
Private Duty Nursing Program For Medically Fragile Children - form #432301 To apply for the Medically Fragile Children PDN Enhancement, complete this form

OMIG Provider Compliance Certification - Confirmation notice for the OMIG Provider Compliance Program may be required. Visit www.omig.ny.gov to determine if the Applicant / Provider must comply. If yes, a copy of the confirmation notice (printed from the website) must be included with this application.

Change of Address - form #610101
Disclosure Form for Practitioners - form #380104
EFT Attestation Form - form #701102
Prior Conduct Questionnaire - form #431001 (If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form).
Private Duty Nursing Program For Medically Fragile Children - form #432301 To apply for the Medically Fragile Children PDN Enhancement, complete this form