Medicaid Enrollment Form

New York Medicaid (eMedNY) instituted a new provider enrollment form to submit a new provider enrollment request to the Medicaid program. The new EMEDNY-436801, with a revision date of May 2015, now replaces the old EMEDNY-408601. The new form and instructions are available on the eMedNY website. Questions can also be directed to Computer Sciences Corporation at 800-343-9000. Because the submission of outdated forms can result in those submissions being rejected, eMedNY is recommending as a general rule to always confirm that you are using the latest version of any form being submitted.

Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827