Pay BillThe New York State Department of Health (NYSDOH) requires all participating providers 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 requests all participating providers complete and submit this double-sided form to Independent Health. 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.
Independent Health sends this form to providers during the credentialing or contracting process. Providers should complete a new form if there is a change to their practice (ownership, demographics, TIN, etc.)
Where to submit the form
Providers may e-mail this completed form to NetworkOperations@independenthealth.com
Page updated 9/2026