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new york state department of health emedny- ( / ) page of change of address form for practitioners, businesses and groups general instructions • pages , and of the change of address form must be returned. red ink, white out and double-sided forms are unacceptable. this form is only for fee for service
providers. • page : list the medicaid provider number, npi (required, unless npi exempt,) category of service and provider name. • page : list the new correspondence, pay to, and corporate addresses, if applicable. if no changes to these addresses, leave blank. • provider's original signature is required...
https://www.emedny.org/info/ProviderEnrollment/ProviderMaintForms/610101_BPGCOA_FRM_Address_Change_Form.pdf