New York State Medicaid Enrollment Form

SECTION 2: Ownership in Other Disclosing Entities (ODE) (per 42 CFR, Part 455.104(a)(3)) - (Complete if any identified in Section 1 has an ownership or control interest in ODE) Name (from Section 1) Name of ODE NPI or Medicaid ID of ODE Name (from Section 1) Name of ODE NPI or Medicaid ID of ODE SECTION 3:

  York, States, Section, New york state

PLEASE READ CAREFULLY THE FOLLOWING INFORMATION …

The undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring pre-authorization pursuant to the Medical Treatment Guidelines.Do NOT use this form for injuries/illnesses involving the Mid and Low Back, Neck, Knee, Shoulder, Carpal Tunnel Syndrome and Non-Acute Pain, except for the treatment/procedures listed below under