Forms

The following forms need to be signed and filled out in order for us to get started:

1. Medicare EDI Enrollment Form
   Print form sign where indicated (we will complete the rest)
   
   
2. Medicaid Certification Statement
   print page 3 of this form sign and notorize.
   
   
3. Medicare ERN (electronic remittance notice)
   Since Medicare is eliminating paper EOB’s.  We download the remittance directly from Medicare, post the charges and bill the secondaries.  If you want to receive a copy of your Medicare EOB’s we can email, fax or mail them to you.
   
   
4. Medicare EFT (electronic funds transfer)
   Authorization Agreement for Electronic Funds Transfer (EFT)
   Medicare will deposit any Medicare payments directly into your bank account making funds available to you.

Must attach a voided check, preprinted deposit slip, or a confirmation of account information on bank letterhead for verification of your account number.

Please mail forms to:
Empire Medicare Services
Provider Enrollment Department
POB 1200
Crompond , NY 10517

If you need any assistance with the completion of the EFT or FRN forms, please contact an
EMC Marketing Analyst at 212-476-7952 or 212-476-7934.
Medicaid EFT
Information on GHI EFT
Information on United Healthcare EFT and ERN

Medicare enrollment or reassignment forms:

1. CMS 855A-Medicare Enrollment Application for Institutional Providers
2. CMS 855B-Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers
3. CMS 855I -Medicare Enrollment Application for Physicians and Non-Physician Practitioners
4. CMS 855R--Medicare Enrollment Application for Reassignment of Medicare Benefits
5. CMS 855S-Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
   

Medicaid change of address form/adding a location
For Medicaid claims, each location where a provider sees patients needs to be listed with Medicaid and a locator code is generated for each location.  Without the locator code claims will be rejected.  Please fill out the form below to add locations or change an address.