Provider Index > Applied Behavior Analysis (ABA) > Licensed Behavior Analysts (OPRA to Billing)

Provider Enrollment & Maintenance

Complete this Enrollment Form if you are:

any ownership related information, and
managing employees, those with a control interest, and agents

IF CHANGES HAVE OCCURRED, DO NOT SUBMIT THIS FORM.
Instead, You Must Complete A New Enrollment Form for Billing Providers.

OPRA to Billing Enrollment Form

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email. Please note, the Medicaid Pending Provider Listing lists all applications that are in process, and the Medicaid Enrolled Provider Listing lists all enrollments that have been approved.

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 be valid on the application date and continuously valid through the current date.
- An original signature is required. 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, as requests for copies cannot be honored.
- Valid telephone numbers are required for each service address.
- Do Not submit documentation containing recipient information with your application (e.g., paper claims forms, recipient insurance verification documents, etc.).
Requirements & Additional Forms
PLEASE NOTE: Only complete applications containing all requirements and additional forms will be accepted for processing. Applications with missing or incomplete information will be rejected and returned
Additional forms which may be REQUIRED to complete your enrollment:
Mailing Instructions
1. Keep a copy of all documents submitted, as requests for copies will not be honored.
2. Send the completed enrollment form, required documents and additional forms to:
STANDARD MAILING EXPEDITED / PRIORITY MAILING
eMedNY
P.O. Box 4603
Rensselaer, NY 12144-4603 eMedNY
ATTN: Box 4603
327 Columbia Turnpike
Rensselaer, NY 12144

STANDARD MAILING	EXPEDITED / PRIORITY MAILING
eMedNY P.O. Box 4603 Rensselaer, NY 12144-4603	eMedNY ATTN: Box 4603 327 Columbia Turnpike Rensselaer, NY 12144

Supplemental Information

Applied Behavior Analysis Manual

151-12:19:47 PM

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