Provider Enrollment > Provider Maintenance Forms

Provider Maintenance Forms

PLEASE TAKE NOTE: We recently removed many of the maintenance forms from this page. Links to forms such as Change of Address and Request to Participate as a Group Member are now accessed on the Provider Enrollment page by clicking on your provider type.

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

= Available on the Provider Enrollment Portal

ETIN Information

Certification Statement/Instructions for Existing ETINs
Default Electronic Transmitter Identification Number (ETIN)
Selection Form CLICK HERE
to Complete this form on the new Provider Enrollment Portal
Note: Available for Practitioners Only
Electronic Funds Transfer (EFT) Authorization Form CLICK HERE
to Complete this form on the new Provider Enrollment Portal
Note: Available for Practitioners Only

NOTE: Instead of filling out the EFT Authorization Form above, you can complete the form online at: https://portal.emedny.org/provider/

Electronic Prior Approval Request Form
Electronic or PDF Remittance Advice Request

NOTE: Instead of filling out the Electronic or PDF Remittance Advice Request Form above, you can complete the form online at: https://portal.emedny.org/provider/

Paper Remittance Sort Request Form