Dear Applicant: Thank you for your interest in enrolling in the New York State Medicaid Program. Participation in the New York State Medicaid Program is an important undertaking. Therefore, we want to make you aware of the following factors concerning your potential enrollment as a provider: x An enrollment application does not guarantee enrollment in the Medicaid Program. x At this time the Department does not enroll mail order pharmacies. Mail order pharmacies are defined as pharmacies which provide more than 15% mail order pharmacy services. x If your application is approved, the effective date of your enrollment will be specified by the Department. x You will be at financial risk if you render services to Medicaid patients before successfully completing the enrollment process. Payment will not be made for any claims submitted for service, care or supplies furnished before the enrollment date authorized by the Department. x Services rendered to Medicaid beneficiaries at your service address may not be billed through any other provider number. If you provide services at your service location that are subsequently billed through another provider number, including a provider number issued to another location under the same ownership, your application will be denied and action will be taken against the billing provider. x All of the information reported by you on the application will be verified by the Department before your acceptance into the Medicaid Program. x Enrollments for New York City, Nassau, Rockland, Suffolk and Westchester Counties, out of state, ownership changes, previous terminations and sanctions are subject to further review. x Subsequent requests for information concerning your application must receive a response within the time frames specified by the Department or your application is subject to termination. x Enrollment may be denied for failure to accurately or completely disclose information during the application process and for any other factors the Department determines to be applicable. x All enrolled pharmacies MUST participate in the mandatory Prospective Drug Utilization Program (ProDUR) to receive reimbursement. This important ProDUR information and certification requirements (separate from the enrollment requirement) can be accessed online at www.eMedNY.or g. Click on Provider Manuals and select the Pharmacy Manual. The ProDur/ECCA Provider Manual is contained in the Pharmacy Manual. First you will receive an inactive prereview letter advising you to use your National Provider Identifier (NPI)/Medicaid Provider #. Please note this letter does not constitute approval in the Medicaid Program. Until you are approved, your NPI/Medicaid Provider # may be used SOLELY to allow testing of your software so that you can comply with the mandatory on-line ProDUR. New York State Medicaid Regulations allow the Department 90 calendar days after receipt of a complete application to determine whether to enroll an applicant in the program. 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 18 NYCRR which can be found at the Department of Health’s website, www.health.state.ny.us. In addition, pursuant to 42 CFR §455.105, by enrolling in the Medicaid Program, you are entering into an agreement with the NYS Department of Health by which you agree to and may be requested to provide the following information within 35 days upon request by the Department or the Secretary of Health and Human Services. 1. The ownership of any subcontractor with whom you have 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 you and any wholly owned supplier, or between you and any subcontractor, during the 5 year period ending on the date of the request. If you have any questions, please contact the eMedNY Call Center at 1-800-343-9000. Sincerely, Bureau of Provider Enrollment Fee for Service Operations Group Division of OHIP Operations Pharmacy EMEDNY-409101 (10/11) MEDICAID PROVIDER ENROLLMENT PHARMACY/SUPERVISING PHARMACIST FORM CHECKLIST THE FOLLOWING INFORMATION MUST BE PROVIDED TO PROCESS YOUR ENROLLMENT APPLICATION. FAILURE TO SUBMIT REQUIRED INFORMATION MAY RESULT IN YOUR APPLICATION BEING RETURNED TO YOU AND WILL DELAY THE ENROLLMENT PROCESS. REQUIRED FIELDS TO BE COMPLETED ON THE ENROLLMENT FORM CATEGORY OF SERVICE (COS) PAY TO ADDRESS APPLICATION TYPE SERVICE ADDRESS APPLICANT NAME ALL YES/NO QUESTIONS MUST BE ANSWERED** NATIONAL PROVIDER IDENTIFIER (NPI) DEA NUMBER IF DISPENSING CONTROLLED SUBSTANCES FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) OWNER’S SIGNATURE CORRESPONDENCE ADDRESS *IF REINSTATEMENT IS CHECKED PLEASE SEE REQUIRED DOCUMENTATION ON PAGE 2 OF 2 OF THIS CHECKLIST. **IF YES ANSWERED TO ANY OF THE FOUR QUESTIONS, YOU MUST COMPLETE THE “PRIOR CONDUCT QUESTIONNAIRE” AVAILABLE ON THE WWW.EMEDNY.ORG WEBSITE. YOU ARE REQUIRED TO PROVIDE DOCUMENTATION AND/OR DETAILS EXPLAINING THE CIRCUMSTANCES. REQUIRED DOCUMENTATION TO BE SUBMITTED MEDICAID PROVIDER ENROLLMENT: PHARMACY FORM COPY OF DEPARTMENT OF TREASURY, INTERNAL REVENUE SERVICE LETTER ASSIGNING YOUR FEIN COPY OF CURRENT LICENSE/REGISTRATION COPY OF THE LEASE DISCLOSURE OF OWNERSHIP AND CONTROL – BUSINESS ENTITY FORM COPY OF YOUR DEA CERTIFICATE IF YOU ARE DISPENSING CONTROLLED SUBSTANCES PHARMACY INFORMATION REQUEST FORM COPY OF MEDICARE AWARD LETTER BALANCE SHEET WITH SPECIFIC LINE ITEM ASSET INFORMATION PERSONAL IDENTIFICATION NUMBER (PIN) REQUEST FORM HOSPITAL, NURSING HOME, CLINIC BASED PHARMACY QUESTIONNAIRE SUBMIT THE OFFICE OF MEDICAID INSPECTOR GENERAL (OMIG) PROVIDER COMPLIANCE CONFIRMATION (IF APPLICABLE). FOR MORE INFORMATION, GO TO THE OMIG WEBSITE, COMPLIANCE SECTION AT WWW.OMIG.NY.GOV. EMEDNY-409202 (11/10) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com AFTER THE PROVIDER IS ENROLLED AND RECEIVES A PROVIDER ID, AN ELECTRONIC/PAPER TRANSMITTER IDENTIFICATION NUMBER APPLICATION AND A CERTIFICATION STATEMENT (LOCATED AT WWW.EMEDNY.ORG) MUST BE SUBMITTED FOR ELECTRONIC SUBMISSIONS. SUPERVISING PHARMACIST IF NOT CURRENTLY ENROLLED MEDICAID PROVIDER ENROLLMENT: SUPERVISING PHARMACIST FORM (EMEDNY4098) SUPERVISING PHARMACIST AGREEMENT FORM (EMEDNY-4099) COPY OF SUPERVISING PHARMACIST’S CURRENT LICENSE/REGISTRATION RENEWAL CERTIFICATE DISCLOSURE OF OWNERSHIP AND CONTROL – INDIVIDUAL FORM PASSPORT SIZE PHOTO OF THE SUPERVISING PHARMACIST AFFIXED TO A SEPARATE 8 ½” x 11” SHEET OF PAPER WITH SUPERVISING PHARMACIST NAME, SOCIAL SECURITY NUMBER AND NAME OF PHARMACY IF CURRENTLY ENROLLED SUPERVISING PHARMACIST AGREEMENT FORM (EMEDNY-4099) REINSTATEMENTS AN APPLICATION IS CONSIDERED TO BE A REINSTATEMENT IF THE APPLICANT WAS PREVIOUSLY EXCLUDED/TERMINATED FROM THE MEDICAID PROGRAM AS A RESULT OF COMMITTING AN UNACCEPTABLE PRACTICE, DISCIPLINE ACTION TAKEN AGAINST THEIR LICENSE, INDICTMENT, CONVICTION OR MEDICARE EXCLUSION. IF YES ANSWERED TO ANY OF THE FOUR QUESTIONS, YOU MUST COMPLETE THE PRIOR CONDUCT QUESTIONNAIRE AVAILABLE AT WWW.EMEDNY.ORG. YOU ARE REQUIRED TO PROVIDE DOCUMENTATION AND/OR DETAILS EXPLAINING THE CIRCUMSTANCES. IF YOU ANSWER YES TO THE FIRST OF THE YES/NO QUESTIONS BECAUSE YOU WERE EXCLUDED, TERMINATED, SANCTIONED, OR RESTRICTED BY AN AGREEMENT FROM ANY MEDICAID PROGRAM AND/OR MEDICARE PROGRAM YOU MAY BE REQUESTED TO SUPPLY INFORMATION AND/OR DOCUMENTATION DETAILING ALL CORRECTIVE STEPS YOU HAVE TAKEN TO DEMONSTRATE THE VIOLATIONS THAT LED TO YOUR EXCLUSION/TERMINATION WILL NOT BE REPEATED. EXAMPLES: RE-EDUCATION COURSES; ATTESTATIONS FROM THIRD PARTY PAYERS; REPORTS FROM QUALITY ASSURANCE COMMITTEES REGARDING REVIEW OF RECORDS; MEDICARE REINSTATEMENT PLEASE NOTE: IF AN APPLICANT IS DENIED REINSTATEMENT, THE APPLICANT CANNOT RE-APPLY FOR REINSTATEMENT FOR TWO (2) YEARS FROM THE DATE OF THE DENIAL. Page 2 of 2 EMEDNY-409202 (11/10) American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com . American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Mail To: Computer Sciences Corporation P.O. Box 4603 Rensselaer, NY 12144 – 4603 New York State Medicaid Disclosure of Ownership and Control – Business Entity Name of Business Entity Note The following questions do NOT only pertain to this provider application but include any and all past activity. Respond to these questions on behalf of yourself and any individuals or organizations having a direct or indirect ownership or control interest of 5% or more, and any partners, directors, officers, agents or managing employees of the provider completing this form. Questions 1. Have you or an entity in which you had an ownership interest over 5% ever been terminated, denied enrollment, suspended, restricted by agreement or otherwise sanctioned by the Medicaid Program in New York or any other state of the United States, Medicare, or any other governmental or private medical insurance program? Yes No 2. Have you ever been convicted of a crime relating to the furnishing of, or billing for, medical care, services, or supplies or which is considered an offense involving theft or fraud or an offense against public administration or against public health and morals? Yes No 3. Has your business or professional license or certification or the license of an entity in which you had an ownership interest over 5% ever been revoked, suspended, surrendered, or 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? Yes No 5. Type of entity Sole Proprietorship Unincorporated Association Corporation Governmental Partnership Other (Specify) 6. Has there been a change of ownership or control within the last 12 months? Yes No If “Yes,” provide both: / / MM / DD / YY Medicaid # or National Provider Identifier (NPI) 7. Do you anticipate a change of ownership within the next 12 months? Yes No If “Yes,” give date / / MM / DD / YY 1 EMEDNY-490201 (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 8. Ownership Information: Who Must Disclose Individual or corporation with an ownership control interest (direct or indirect of 5% or more), managing employees of the disclosing entity, subcontractor with 5% or more interest in the disclosing entity, other disclosing entities in which an owner of the disclosing entity has an ownership or control interest. What to Disclose Name, address of any person (individual or corporation) with an ownership or control interest in the disclosing entity. Date of birth (DOB) and Social Security Number (SSN) for individuals and tax identification number (EIN) for corporations. Include familial relationship (spouse, parent, child, sibling) to other persons with ownership and control interest in the disclosing entity and subcontractors with 5% or more interest in the disclosing entity. Corporate entities must attach a separate list of every business location and PO Box address. For definitions of ownership, indirect ownership, managing employee refer to Part 504 of 18 NYCRR. For complete set of rules and regulations refer to Federal Register Vol. 76 No 22 §455.104. Failure to provide the required information may result in denial of enrollment. This page may be photocopied for additional listings. Name Title Address SSN/EIN Title: DOB Owner Board Director % Ownership Managing Employee Name Familial Relationship Title Address SSN/EIN Title: DOB Owner Board Director % Ownership Managing Employee Name Familial Relationship Title Address SSN/EIN Title: DOB Owner Board Director % Ownership Managing Employee Name Familial Relationship Title Address SSN/EIN Title: DOB Owner Board Director % Ownership Managing Employee 2 EMEDNY-490201 (07/11) Familial Relationship American LegalNet, Inc. www.FormsWorkFlow.com 9. Is this facility operated by a management company, or leased in whole or in part by another organization? Yes No If “Yes,” give date / / MM / DD / YY 10. Has there been a change in your laboratory director/supervising pharmacist within the last 12 months? Yes No Not Applicable 11. Do you currently have any unpaid balances owed to the Medicaid Program? Yes No If “Yes,” indicate amount $ o Has payment been arranged? Yes No If “Yes,” please attach verification of this. 12. If this application is for a change of ownership or an impending change of ownership, are you assuming all current or future liabilities owed by the seller to the Medicaid program for the entity that you have purchased or are purchasing? Yes No Not Applicable 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 percent interest) may be required to consent to criminal background checks including fingerprinting. 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 18 NYCRR which can be found at the Department of Health’s website, http://health.ny.gov. In addition, pursuant to 42 CFR §455.105, by enrolling in the Medicaid Program, you are entering into an agreement with the NYS Department of Health by which you agree to and may be requested to provide the following information within 35 days upon request by the Department or the Secretary of Health and Human Services. 1. The ownership of any subcontractor with whom you have 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 you and any wholly owned supplier, or between you and any subcontractor, during the 5 year period ending on the date of the request. 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 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 of Health and Human Services, as appropriate. Owner/Board Member Name (printed) Signature (No stamps) 3 EMEDNY-490201 (07/11) Date American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Yes If the ‘yes’ box above was not checked, the following information must be provided to process your enrollment application. Failure to submit required information may result in your application being returned to you and will delay the enrollment process. Attach additional sheets when necessary. Are you presently open? Yes No / If yes, when did you open? M / If no, when you anticipate opening? M 1. / D / M / D / D / Y Y Y / Y / D List the name of the owner(s) of the business and their social security number(s) and percentage of ownership. List any New York State (NYS) Medicaid Program provider numbers, National Provider Identifiers (NPI) or professional licenses held by the owners. If a corporation or partnership, list the names of the officers, directors, principal stockholders, partners and their social security numbers and any NYS Medicaid Program provider numbers or professional licenses held. 2. / M - Leasehold arrangements: a. Indicate whether rent is paid in equal monthly or yearly installments. b. Submit a description of any other payments to be made as, or in lieu of, rent to the owner of the property. c. Provide the name and address of the owner(s) of the building(s) to be used by the business. If a corporation or partnership, list the names of the officers, directors, principal stockholders, partners and their social security numbers. - - Page 1 of 4 EMEDNY-409501 (01/10) American LegalNet, Inc. www.FormsWorkFlow.com d. Provide the name and address to whom the rent is paid. Attach a copy (front and back) of the most recent canceled rent check. e. If rent is paid to a corporation or partnership, list the names of the officers, directors, principal stockholders, partners and their social security numbers and any NYS Medicaid Program provider numbers, National Provider Identifiers or professional licenses held. - - 3. If the business location was previously a place at which NYS Medicaid pharmacy services were rendered, list the NYS Medicaid Provider Number/National Provider Identifier(s) of the prior owner(s). 4. Enclose copies of any promissory notes, sales agreements and any other relevant documents pertaining to the sale. 5. Estimate the dollar value of the pharmaceutical stock and medical supplies currently on hand. Please attach a detailed list of your current inventory. (If there has recently been an ownership change, submit all supplier invoices or inventories from previous owners that verify stock on hand.) 6. Estimate the percentage of business that will be billed to the NYS Medicaid Program. % 7. a. Identify the name, address and account number(s) of the bank(s) to be used by the business. b. Provide the names and social security numbers of all personnel authorized to sign corporate checks against those accounts. 8. - Attach a statement identifying the persons who will be authorized to sign NYS Medicaid Program claims and provide original examples of their signatures. Page 2 of 4 EMEDNY-409501 (01/10) American LegalNet, Inc. www.FormsWorkFlow.com 9. List the name and license number of each pharmacist. State the days and hours of the week the pharmacist will be working. 10. Indicate the days and corresponding hours the pharmacy will be open. Monday Tuesday Wednesday Thursday 11. to to to to Friday Saturday Sunday to to to Indicate which services your pharmacy provides and how they are provided. a. Free delivery. any limitations. b. Emergency service: a. b. After hours phone number After hours beeper number c. Health counseling (e.g. blood pressure checks, diabetic care, etc.) c. d. Multilingual counseling. the language(s) spoken and indicate which pharmacist or supervising pharmacist speaks the language(s) listed. d. e. Multilingual labeling. language(s). e. f. the Compound prescriptions. f. g. Private consultation area. g. h. Patient information leaflets. h. i. Drug and allergy monitoring. i. j. How does your establishment provide access j. to the handicapped (ramps, passage, parking, etc.)? Identify any additional circumstances or services which you offer that significantly improve health services to your clients other than those listed above. Page 3 of 4 EMEDNY-409501 (01/10) American LegalNet, Inc. www.FormsWorkFlow.com 12. Explain how your customers are made aware of the services your pharmacy provides. 13. Of your total pharmacy revenue, what percentage is provided by mail order or delivery (i.e. Fed Ex, UPS, US Mail, etc.)? a. Identify the types of medication or supplies that you provide by mail order or delivery. b. How do you provide these services to your customers? c. Where do the customers that receive these services reside? 14. Provide the name and telephone number of the accountant for the business. 15. Provide the name, address and telephone number of the attorney for the business. 16. a. Are you an out of state provider of pharmacy services interested in participating in the NYS Medicaid Program? Yes No b. Is this application for a single occasion for one NYS Medicaid Program recipient? Yes No c. If yes, please provide the first date of service for this recipient. / / / M M D D / / Y Y Owner’s Name (Print): Owner’s Signature: (Signature Stamps Are Not Permitted) Date Signed: Application Prepared by (Print): Telephone Number: Page 4 of 4 EMEDNY-409501 (01/10) American LegalNet, Inc. www.FormsWorkFlow.com ______________________________ _____________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Mail To: Computer Sciences Corporation P.O. Box 4603 Rensselaer, NY 12144 – 4603 New York State Medicaid Disclosure of Ownership and Control – Individual Note The following questions do NOT only pertain to this provider application but include any and all past activity. Respond to these questions on behalf of yourself and any individuals or organizations having a direct or indirect ownership or control interest of 5% or more, and any partners, directors, officers, agents or managing employees of the named provider completing this form. Questions 1. Have you or an entity in which you had an ownership interest over 5% ever been terminated, denied enrollment, suspended, restricted by agreement or otherwise sanctioned by the Medicaid Program in New York or any other state of the United States, Medicare, or any other governmental or private medical insurance program? Yes No 2. Have you ever been convicted of a crime relating to the furnishing of, or billing for, medical care, services, or supplies or which is considered an offense involving theft or fraud or an offense against public administration or against public health and morals? Yes No 3. Has your business or professional license or certification or the license of an entity in which you had an ownership interest over 5% ever been revoked, suspended, surrendered, or 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? Yes No 5. Has there been a change of ownership or control within the last 12 months to any of the above entities? Yes No If “Yes,” provide both: / / MM / DD / YYYY Medicaid # or National Provider Identifier (NPI) 6. Do you anticipate a change of ownership within the next 12 months to any of the above entities? Yes No If “Yes,” give date / / MM / DD / YYYY 1 EMEDNY-490201 (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 7. Ownership Information: Who Must Disclose Individual or corporation with an ownership control interest (direct or indirect of 5% or more), managing employees of the disclosing entity, subcontractor with 5% or more interest in the disclosing entity, other disclosing entities in which an owner of the disclosing entity has an ownership or control interest. What to Disclose Name, address of any person (individual or corporation) with an ownership or control interest in the disclosing entity. Date of birth (DOB) and Social Security Number (SSN) for individuals and tax identification number (EIN) for corporations. Include familial relationship (spouse, parent, child, sibling) to other persons with ownership and control interest in the disclosing entity and subcontractors with 5% or more interest in the disclosing entity. Corporate entities must attach a separate list of every business location and PO Box address. For definitions of ownership, indirect ownership, managing employee refer to Part 504 of 18 NYCRR. For complete set of rules and regulations refer to Federal Register Vol 76 No 22 §455.104. Failure to provide the required information may result in denial of enrollment. This page may be photocopied for additional listings. Name Title Address SSN/EIN Title: DOB Self/Owner Board Director % Ownership Managing Employee Name Familial Relationship Title Address SSN/EIN Title: DOB Owner Board Director % Ownership Managing Employee Name Familial Relationship Title Address SSN/EIN Title: DOB Owner Board Director % Ownership Managing Employee Name Familial Relationship Title Address SSN/EIN Title: DOB Owner Board Director % Ownership Managing Employee Familial Relationship 2 EMEDNY-490201 (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 8. Do you currently have any unpaid balances owed to the Medicaid Program? Yes No If “Yes,” indicate amount $ o Has payment been arranged? Yes No If "Yes,” please attach verification of this. 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 percent interest) may be required to consent to criminal background checks including fingerprinting. 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 18 NYCRR which can be found at the Department of Health’s website, http://health.ny.gov. In addition, pursuant to 42 CFR §455.105, by enrolling in the Medicaid Program, you are entering into an agreement with the NYS Department of Health by which you agree to and may be requested to provide the following information within 35 days upon request by the Department or the Secretary of Health and Human Services. 1. The ownership of any subcontractor with whom you have 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 you and any wholly owned supplier, or between you and any subcontractor, during the 5 year period ending on the date of the request. 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 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 of Health and Human Services, as appropriate. Name & Title (printed) Signature (No stamps) Date 3 EMEDNY-490201 (07/11) American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com