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eMedNY ETIN Certification Forms

The eMedNY ETIN Certification forms allow the IFA to bill on behalf of the provider.  The Certification Statement associates the IFA's ETIN with the provider's NPI number, and the ERA Request form allows the IFA to receive ERA's rather than having those sent directly to the provider.  That information will then be available to the provider in reports on EIBilling.com.

Click here to download the Certification Statement and ERA Request Form to be filled out for eMedNY.  Please note that this form is pre-filled with the necessary information for the IFSA.  The provider will need to fill in the appropriate blank fields.

For instructions on filling out the Certification Statement, which has EMEDNY-490601 in the bottom left corner,click here.

For the ERA Request Form, which has EMEDNY-700201 in the bottom left corner, you will need to complete Sections A, B, and D.  In Section B, "eXchange" should be checked off, and "EIBillin" should be listed as the User ID #.

**Please note that on both forms, you will need to include both your NPI and Medicaid Provider number if possible.

Article ID: 64, Created On: 5/9/2013, Modified: 4/14/2014

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