The New York State Department of Health (NYSDOH) recently released an updated Participating Provider Owner/Manager Disclosure Certification form that each participating practice is required to complete to verify compliance with the statutes, rules, regulations, and applicable Medicaid Updates governing the provision of care, services, and/or medical supplies under the Medicaid program.
Therefore, Independent Health is requesting all participating providers complete and submit this double-sided form to Independent Health by June 1, 2019. Providers who are individually contracted with Independent Health must each sign and submit the form themselves. Providers who are part of group contracts should have their group sign and submit the form on their behalf.
Please submit this completed certificate to Independent Health through one of the following:
- Email as an attachment to firstname.lastname@example.org
- Mail it to Independent Health, Attn.: Network Contract Management, 511 Farber Lakes, Dr., Buffalo, NY 14221