Provider Enrollment > Provider Maintenance Forms

Provider Maintenance Forms

All forms and packets are typeable.
This enhancement alleviates problems related to legibility of the information entered on the forms.

Please open and type your information into the form, then print, sign and mail in to eMedNY.
Please use the tab key or the mouse to move from field to field on typeable forms.

Miscellaneous Maintenance Forms

ETIN Information

1099 Duplicate Request Form
Certification Statement/Instructions for Existing ETINs
Copy of Cleared Check Form
Default Electronic Transmitter Identification Number (ETIN)
Selection Form
Electronic Prior Approval Request Form
ETIN Name and Address Change
Paper Remittance Sort Request Form
Payment Listing Form
Pay-To-Group Only Qualifier Removal Request Form

Pended Claim Recycle Request Form
Prior Approval Roster Request Form
Provider Electronic/Paper Transmitter Identification Number (ETIN)
Provider ID Request Form
Remittance Copy Request Form
Request For Provider Reports
Request to Disaffiliate/Delete an ETIN
Service Bureau Electronic/Paper Transmitter Identification Number (ETIN)
Stop and Reissue Request Form