Category(s) of Service: 0460

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

Provider Index > Physician > Billing Medicaid

Provider Enrollment & Maintenance Instructions

Billing Medicaid

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
- Application as a Specialist if applicable
- DEA Form Completion is required, failure to complete this form may cause your application to be rejected and returned.Additional Instructions for form completion:
  If you are licensed to and DO prescribe, administer, or dispense controlled substances, you are required to complete only Sections A and C.
  If you are licensed to but do NOT prescribe, administer, or dispense controlled substances, you are only required to complete only Sections A and B.
  Note for practitioners: If employed by an institution and authorized to use the Institution's DEA, submit a copy of that DEA and proof of the suffix/identifier assigned to you by the Institution.
- 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).
- NDPP Recognition Attestation Providers applying to become a National Diabetes Prevention Program (NDPP) service provider must complete this attestation recognition form.
- Office Based Surgery Program To apply for Office Based Surgery, complete this form
- Physician Office Lab - CLIA Information To apply for Physician Office Laboratory-CLIA, complete this form
- PPAC Phys Addendum For Enrollment as a Specialist Applicants to PPAC MUST complete this ADDENDUM to Application for Enrollment as a Medical or Dental Specialist.
- PPAC Physician Program Description To apply for the Preferred Physicians and Children Program (PPAC), also complete this form.
- 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.
- DEA Certificate
  If you do NOT prescribe, administer, or dispense controlled substances, then you do NOT need to submit a DEA certificate. You must, however, complete and submit the DEA Form (EMEDNY #610301) found below.
  
  If you DO prescribe, administer, or dispense controlled substances, then you must submit a copy of your DEA certificate or a web-based printout from the Office of diversion Control website at https://www.deadiversion.usdoj.gov/webforms/dupeCertLogin.jsp and complete the DEA Form (EMEDNY #610301). If employed by an institution and authorized to use the institution’s DEA, you must submit a copy of the institution’s DEA certificate and proof of the suffix/identifier assigned to you by the institution.
- 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
- Application as a Specialist if applicable
- Change of Address
- DEA Form Completion is required, failure to complete this form may cause your application to be rejected and returned.Additional Instructions for form completion:
  If you are licensed to and DO prescribe, administer, or dispense controlled substances, you are required to complete only Sections A and C.
  If you are licensed to but do NOT prescribe, administer, or dispense controlled substances, you are only required to complete only Sections A and B.
  Note for practitioners: If employed by an institution and authorized to use the Institution's DEA, submit a copy of that DEA and proof of the suffix/identifier assigned to you by the Institution.
- 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).
- HIV Enhanced Fee Payment Program To apply for HIV Enhanced Fee Payment, also complete this form.
- NDPP Recognition Attestation Providers applying to become a National Diabetes Prevention Program (NDPP) service provider must complete this attestation recognition form.
- Notification of Status as Group-only Practitioner
- Office Based Surgery Program To apply for Office Based Surgery, complete this form
- Physician Office Lab - CLIA Information To apply for Physician Office Laboratory-CLIA, complete this form
- PPAC Phys Addendum For Enrollment as a Specialist Applicants to PPAC MUST complete this ADDENDUM to Application for Enrollment as a Medical or Dental Specialist.
- PPAC Physician Program Description To apply for the Preferred Physicians and Children Program (PPAC), also complete this form.
- 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.
- Request for Dispensing Physicians to Bill Pharmacy Claims - Enrollment of physician dispensers has been paused due to delay in the pharmacy carve-out. Please refer to future editions of the Medicaid Update for status updates.

Last Updated: 1/2025

Supplemental Information

Physician Manual