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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 o

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

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