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Get and Sign the Department of Healths Website, Www Form
Practitioner (attending providers
should use this form if their name and NPI will only appear on the hospital’s claim).
These providers will not submit claims to Medicaid and, therefore will not receive
payment from the Medicaid Program or,
2. A Medicaid Managed Care Network provider.
If you will also provide medical services to patients, or as an attending provider will submit a
separate claim to Medicaid for your service, do not complete this form. Visit
www.eMedNY.org and complete the...
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Handy tips for filling out Ny medicaid form online
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