EMEDNY-380103 (10/20)
3. Have any of these individuals/entities ever had their business or professional license or certification,
or the license of an entity in which they had an ownership interest over 5% ever been revoked, suspended,
surrendered, or in any way restricted by probation or agreement by any licensing authority in any State?
Yes
No
4. Is there currently pending any proceedings that could result in the above stated sanctions for these
individuals/entities ?
Yes
No
NOTE:
All questions must be answered.
If you answered “Yes” to any of the questions above, you must
complete and submit the “Prior Conduct Questionnaire” available at www.eMedNY.org.
Please continue and Answer Question 5.
5. Does the Provider have any unpaid balances owed to the NY Medicaid Program related to this
Business or another entity owned by the Applicant?
Yes
No
• If yes, indicate amount $_____
• If yes, has payment been arranged? Yes No If yes, attach verification of arrangement.
If no, this enrollment will be reviewed by the OMIG
By signing this form, the
Provider understands and agrees to the following:
As a Medicaid Provider you agree to comply with the rules, regulations and official directives of the Department
including, but not limited to Part 504 of 18NYCRR which can be found at the Department of Health’s website,
www.health.ny.gov
In addition, pursuant to 42 CFR, Part 455.105, by enrolling in the Medicaid Program you agree to disclose the
following regarding business transactions within the next 35 days upon request of the Department or the Secretary
of He
alth and Human Services.
(1) Information about the ownership of any subcontractor with whom the provider has had business
transactions totaling more than $25,000 during the 12-month period ending on the date of the request, and
(2) Any significant business transactions between the provider and any wholly owned supplier, or between
the provider and any subcontractor during the 5-year period ending on the date of the request.
As a Medicaid Provider you agree to abide by all applicable Federal and State laws as well as the rules and
regulations of other New York State agencies particular to the type of program covered by this enrollment
application.
For those providers for whom the Mandatory Compliance Law applies
(https://omig.ny.gov/compliance/compliance), the Provider has certified via the CERTIFICATION STATEMENT
FOR PROVIDER BILLING MEDICAID that the provider adopted, and implemented, where applicable, an
effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied
the requirements of Title 18 of the New York Code, Rules and Regulations, Part 521.
Unannounced site visits by Medicaid, CMS or their agents/designated contractors may be a condition of initial
and continued enrollment. In addition, the provider and/or owners (defined as at least a 5 % interest) may be
required to consent to criminal background checks including fingerprinting.
As a Medicaid Provider you agree to notify this Department immediately of any changes supplied in this
disclosure document as well as impending ownership changes or any other changes.
The Department may deny or terminate enrollment as a provider in the Medicaid program if it is determined that
executive compensation, bonuses, incentives and costs of administration exceed reasonable levels.
WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR
REPRESENTATION ON THIS STATEMENT MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS.
IN ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION
REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY
PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE STATE AGENCY OR SECRETARY,
AS APPROPRIATE.
__________________________________________________ __________________________________
Authorized Individual* (original; no stamps) Date
*The person signing this document on behalf of the Provider warrants that he/she has legal authority to bind the Provider.