getty-images-uA8AWHiwHGM-unsplash

Forms for Initial Application – Providers

Initial Application Forms

W-9 Form W-9 Form
Disclosure of Ownership Attestation Disclosure of Ownership Attestation
DOH OHIP Participating Provider Owner / Manager Certification Form DOH OHIP Participating Provider Owner / Manager Certification Form
Provider’s Confirmation of Exclusion Process Provider’s Confirmation of Exclusion Process
Roster Template - Provider Information Form Roster Template - Provider Information Form
Contracting Information Form Contracting Information Form
Billing Intake Form Billing Intake Form
Collaborative Agreement Attestation Form Collaborative Agreement Attestation Form
PA Supervision Statement PA Supervision Statement
Sample IRS Letter Sample IRS Letter
Sample Annual eMedNY Medicaid Certification Sample Annual eMedNY Medicaid Certification
last updated: August 21, 2024

Ready to Join Us?

Talk to us about questions or concerns

 866.496.6636 (TTY: 711) 866.496.6636 (TTY: 711)

Monday–Saturday | 8 a.m.–8 p.m. (ET)
Sunday | 9 a.m.–5 p.m. (ET)

Already A Member?

Talk to us about any questions or concerns

 800.303.9626 (TTY 711) 800.303.9626 (TTY 711)

Monday–Saturday | 8 a.m.–6 p.m. (ET)
Sunday | 9 a.m.–5 p.m. (ET)