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CERTIFICATION STATEMENT FOR PROVIDER BILLING …

(1) ETIN _____ (2) BILLING SERVICE NAME (IF APPLICABLE) _____eMedNY/ medicaid MANAGEMENT INFORMATION SYSTEMCERTIFICATION STATEMENT FOR PROVIDER BILLING medicaid (3) As of (date) _____, all claims submitted electronically or on paper to the State's medicaid fiscal agent, for services or supplies furnished(4) by ( PROVIDER name) _____(5) (10-digit National ProviderID (NPI) -- REQUIRED unlessexempted from NPI)(6) (8-digit medicaid ProviderNumber -- If NPI exempt)will be subject to the following am (or the business entity named in this form of which I am a partner, officer, or director is) a qualified PROVIDER enrolled with and authorized toparticipate in the New York State Medical Assistance Program and in the profession or specialties, if any, required in connection with this claim; thepersons providing services, care and supplies have the necessary licensing, CERTIFICATION , training and experience to perform the claimed services; Ihave reviewed these claims; I (or the entity) have furnished or caused to be furnished the care, services, and supplies itemized and done so inaccordance with applicable federal and state laws and regulations; I have read the eMedNY PROVIDER Manual and all revisions thereto; all claims aremade in full compliance with the pertinent provisions of the Manual

Department of Health, the Office of the Medicaid Inspector General, the State Medicaid Fraud Control Unit or the Secretary of the Department of Health and Human Services; there has been compliance with the Federal Civil Rights Act of 1964 and with section 504 of the Federal Rehabilitation Act of ... 8-Digit Medicaid Provider ID Number Enter the ...

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