NYDOH Provider Disclosure Certification

IRS W-9 Form

Amendment Request Form

ADA Accessibility Questionnaire

Disclosure of Ownership Control Interest Statement

Facility Credentialing Application

Demographic Update Request

HIV PCP Attestation (SelectHealth Providers Only)

Social Adult Day Site Visit Toolkit (MLTC Providers Only)

CMS-1500 Form

UB-04 Form

Required Data for Claims Forms

Claims Submission for VNSNY CHOICE Providers

ICD-10 FAQs

Provider Remittance Guide

Billing Instruction for Nursing Home Providers

Claims Layout for Provider Codes

Delegated Roster Submissions

Delegated entities are required to submit monthly/quarterly provider rosters.

The Delegated Entities Provider Roster Template consists of:
• Provider Termination/Add/Update
• Location Termination/Add
• Demographic Updates/Removals

EMR Data Sharing Manual

Opioid Safety Edits

Medicare Part D Link for Formulary List

SelectHealth Opioid Safety Edits

SelectHealth Link for Formulary List

Medicare Part D Coverage Determination Form

SelectHealth Link for Medication Request Form

Medication Adherence Tip Sheet

Quick Reference Guide

SelectHealth Provider Reference Guide

Provider Portal Manual