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ATTENTION: Provider Enrollment Form Change

The old Physician Enrollment Form EMEDNY-408601 is no longer accepted. The form will be rejected by CSC and returned to you. Instead, please use EMEDNY-436801 which currently has a revision date of May 2015.

Each time you submit a new provider enrollment request to the Medicaid Program, access the required forms and instructions directly from the website www.emedny.org.

Form changes may have occurred resulting in your submission being returned because outdated forms were used. This is a good practice to follow when submitting forms to update an existing enrollment file, too. Periodically, confirm that your “Favorites” links are pointed to the latest versions of forms and instructions.

If you have any questions, please contact CSC at 800-343-9000.

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