Category(s) of Service: 0634

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

Provider Index > Dietitian / Nutritionist > Individual Billing Medicaid

Provider Enrollment & Maintenance Instructions

Complete Enrollment in PSP 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

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 Enrollment in PSP
- Each field is identified as mandatory or optional.
- Incomplete applications can be saved at any time and returned to later for modification or completion as long as the application status is "In Process."
- Providers can upload required documentation (as outlined below).
- Valid telephone numbers are required for each service address.
- Once all required information has been entered and documentation has been uploaded, the application should be reviewed for accuracy, and submitted to the State for review.
Click here to begin
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
  - 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 enrollment, i.e., never enrolled)
- Group Member Affiliation/Disaffiliation Request Complete only if you are part of a group practice. (If participating in more than one group, this form must be completed for each additional group).
- Prior Conduct Questionnaire 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, form EMEDNY-490602 (i.e., ETIN for providers who have never been enrolled) or the Certification Statement for Provider Billing Medicaid, form EMEDNY-490601 (i.e., ETIN for providers seeking reinstatement), 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
- Disclosure Form for Practitioners
- EFT Attestation Form
- Group Member Affiliation/Disaffiliation Request Complete only if you are part of a group practice. (If participating in more than one group, this form must be completed for each additional group).
- Prior Conduct Questionnaire 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.

Last Updated: 1/2025

Supplemental Information

Dietitian / Nutritionist Manual