Medical Forms

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

Empire Medicare forms need to be signed for providers with office locations in New York in the following counties: MANHATTAN BRONX, BROOKLYN, NASSAU, ROCKLAND, STATEN ISLAND, SUFFOLK, WESTCHESTER COLUMBIA, DELAWARE, DUTCHESS, GREENE, ORANGE, PUTNAM, SULLIVAN, ULSTER


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.

Empire Medicare EFT form (Authorization Agreement for Electronic Funds Transfer) * optional Medicare will deposit any Medicare payments directly into your bank account making funds available to you.

For EFT enrollment, National Government Services must receive:

A valid Medicare Identification number and NPI
One EFT request form for each Medicare Identification number
A voided blank check or bank affidavit (a pre printed deposit slip will not be accepted)
NOTE: This form cannot be faxed.

Mail forms to: National Government Services
Provider Enrollment
P.O. BOX 4792
Syracuse, NY 13221-4792


GHI Medicare forms need to be signed for providers with practice locations in Queens County, New York (print and sign pages 3-5)

Medicaid Certification Statement print page 3 of this form sign and notorize.

Medicare enrollment or reassignment forms:

CMS 855A -Medicare Enrollment Application for Institutional Providers

CMS 855B - Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers

CMS 855I - Medicare Enrollment Application for Physicians and Non-Physician Practitioners

CMS 855R - Medicare Enrollment Application for Reassignment of Medicare Benefits

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.