Category(s) of Service: 0080

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

Provider Enrollment & Maintenance Instructions

An entity which submits claims, and/or verifies patient eligibility for providers enrolled in the Medicaid Program.

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, or
Reporting an OWNERSHIP CHANGE

PSP Login

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.
- Once an application has started, if not submitted within 45 days it will be deleted from the system. If deleted, the provider must begin the application process again.
- Once submitted, if an application requires additional information, providers will be notified. Failure to respond within 45 days of any request will delay reviewing and processing of the application as it will be withdrawn. If the application is withdrawn, providers will have to apply again.
Click here to begin
Requirements & Additional Forms
PLEASE NOTE: The information below should be reviewed to ensure you are familiar with the appliable requirements and forms that may be requested in the application process. If being prompted to upload a NYS form below, please review the "Step Requirements" hyperlink in the Provider Services Portal (PSP). There you will find a URL to the form, so you may download, complete, then upload with your submission.
- Application Fee ($750) - More information available at Provider Enrollment - Application Fee
- Data Exchange "LINCS" Applicants CPU to CPU
- ETIN Certification Statement (For new enrollment, i.e., never enrolled)
- Prior Conduct Questionnaire If you answer "Yes" to prior conduct disclosure questions you will be prompted to complete and upload this for in the PSP. Note: If an exclusion is found in the Department of Review of your application, you will be required to correct your answer to the appliable questions and to complete this form.
- Service Bureau Application Agreement
- 504.9 Service Bureaus, billing services and electronic media billers CLICK HERE
- For Changes of Ownership ONLY Provide proof that a Change of Ownership has occurred. Examples of proof include but are not limited to a Bill of Sale, Transfer of Ownership, Operating Agreement, Stock Purchase Agreement, etc.
- IRS Assignment Letter indicating the FEIN and Applicant Name on the Enrollment Form (W-9 NOT ACCEPTABLE). IRS Assignment Letter (Form: SS-4) can be obtained by going to IRS.Gov or call IRS at 1-800-829-4933
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.

Last Updated: 5/2026

Supplemental Information