Request for Provider Reports

This form may be used by enrolled providers to request information on their NY Medicaid file. Please check below the report(s) you are requesting.
Please be advised that requests for reports will be processed no more than every six (6) months for the same provider.
Up to 10 different providers can be included on this form. ("Provider Name" and "MMIS ID" fields are expandable.)

Requested Report(s):

Rate Report (Institutional Providers Only)

Locator Code Report

Specialty Code Report

Group Affiliation Report

Requestor Name: (your name)

Requestor Email:

Provider Name	MMIS ID

ReCaptcha:

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