Category(s) of Service: 0580

If you are ALREADY ENROLLED and need to change your address,

click here.

Application Fee is NOT Required

Provider Index > Clinical Psychologist > Individual Billing Medicaid

Provider Enrollment & Maintenance

Complete this Enrollment Form if you are:

Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
Responding to a letter instructing you to REVALIDATE your enrollment, or
Seeking REINSTATEMENT or REACTIVATION of your previous enrollment

PRACTITIONER 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.).
Additional Instructions for the Enrollment Form
Category(s) of Service: Enter the applicable 4-digit code(s) on the Enrollment Form 0580
Choose ONE Application Type and check the corresponding box on the Enrollment Form:
- Check New Enrollment if the NPI or Provider listed is not currently enrolled in NYS Medicaid
- Check Revalidation if the NPI or Provider is currently enrolled and you were notified that Revalidation is required per 42 CFR, Part 455.414. The Provider ID can be found on the Revalidation Letter you received
- Check Reinstatement/Reactivation if the provider was previously enrolled but is not currently active.
  Please note: You will be at financial risk if you render services to Medicaid beneficiaries before successfully completing the enrollment process.
NPI: This field is required.

DEA: Leave Blank

Type of Practice: For each service address, check the box from the list which best describes your type of practice at that address.

Place of Service For each service address, check the box from the list which best describes the site.

Association Types: Enter the letter (B, F, H, I, M, P, or U) which best corresponds to the individual's role. Note: ALL lifestyle coaches providing NDPP services for your organization must be listed in Section 5 of the application as a I-Employee/Lifestyle Coach
B: Board of Directors Member F: Facility Administrator H: Compliance Officer I: Employee/Lifestyle Coach
M: Managing Employee P: Supervising Pharmacist U: Laboratory Director
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
- Electronic Funds Transfer (EFT) Authorization - form #701101
  - For newly enrolling providers, disregard mailing address on form and, instead, submit with enrollment form and supporting documents.
  - Form is not required if submitting a revalidation or reinstatement/reactivation and no changes to the EFT are being requested.
  - Form is not required if you are affiliated with a group and DO NOT have a private practice.
- ETIN Certification Statement for New Enrollments - form #490602 (Not required for revalidation, reinstatement, or reactivation). If you already have an existing ETIN that you wish to affiliate with, submit the Certification Statement for Existing ETINs (EMEDNY 490601) after you receive your Provider ID. This form is available here.
- Group Member Affiliation/Disaffiliation Request - form #610202 (If participating in more than one group, this form must be completed for each additional group).
- Prior Conduct Questionnaire - form #431001 If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
- Proof of current license / registration Examples: 1) Copy of license with future expiration date, 2) Copy of license registration/renewal, or 3) Printout of your license status from the licensing agency’s website.
Provider Compliance Certification - Certification of a Provider Compliance Program may be required. By signing the CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID, you (or the entity) certify that, where required, you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider Compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.
Maintenance Forms
- Change of Address - form #610101 Complete on the PE Portal
- Disclosure Form for Practitioners - form #380104 Complete on the PE Portal
- EFT Attestation Form - form #701102 Complete on the PE Portal
- Group Member Affiliation/Disaffiliation Request - form #610202 Complete on the PE Portal
  (If participating in more than one group, this form must be completed for each additional group).
- Notification of Status as Group-only Practitioner - form #426801
- Prior Conduct Questionnaire - form #431001 Complete on the PE Portal
  If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
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

Last Updated: 4/2024

Supplemental Information

Clinical Psychology Manual

B: Board of Directors Member		F: Facility Administrator		H: Compliance Officer		I: Employee/Lifestyle Coach
M: Managing Employee		P: Supervising Pharmacist		U: Laboratory Director