Electronic Funds Transfer Authorization Request
Fields with * are required
To successfully authorize the use of Electronic Funds Transfer for the depositing of New York Medicaid funds, providers and group practices must complete all required fields on the following pages and print an EFT Attestation form. For more instructions click here. Questions should be directed to eMedNY Call Center at 1-800-343-9000.
Provider Information
: *  
Provider Address
: *  
: *
: *
: *
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Provider Identifiers Information
Provider Identifiers
: *
:   :  
:     
Other Identifiers – Assigning Authority – New York Medicaid
:  
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