Insurance Enrollment Forms

* For new customers in New York State, please follow the instructions below.

*For customers outside of New York state please contact your Project Manager:

To enroll to send claims to New York Medicare directly through MDLand:

Step 1: Click the link below. Complete all fields and agree to the terms, then Submit. This form must then be printed, signed, date and faxed to the EDI Enrollment Department. The fax number is on the printed form.

Submitter Status = 'Existing Submitter'

Submitter Type = 'Clearinghouse'

Submitter Name = 'MDLAND'

NY Medicare Queens (GHI) Submitter Id = NYBQ11383

NY Medicare Downstate (Manhattan/Bronx/Brooklyn/Long Island - Empire Medicare)

Submitter ID = CH0000549


Step 2: Complete the Provider Authorization Form below.

Check the following two boxes:

ASC X12 837 Claim

ASC X12 835 Remittance


NY Medicare Queens (GHI) Submitter Id = NYBQ11383 - NGS Contractor Code = 13292

NY Medicare Downstate (Manhattan/Bronx/Brooklyn/Long Island - Empire Medicare)

Submitter ID = CH0000549 - NGS Contractor Code = 13202


15 East 32nd Street, Fl 2

New York, NY 10016

Tel: 212-363-8000


Step 3: Complete the EDI ERA Enrollment form by clicking the link below (OPTIONAL).


EDI ERA Enrollment Help Worksheet


To enroll to send claims to New York Medicaid directly through MDLand:

Please complete the form below, notarize and mail it to the following address:

Provider Setup


P.O. Box 4614

Rensselaer, NY 12144


To check if the provider ID is ready to submit with our submitter ID please call

(800) 343-9000 option 1

Please make sure that our TSN:05D can be recognized on the form.

Click to Download Medicaid form


NY Medicaid EFT Enrollment:


Enrollment Form

Commerical Electronic Claim Enrollment Form:

MDLand Electronic Claim Form

Commercial Electronic Claim Payer List


ERA Forms:


New York ERA Enrollment Form

Commercial Insurance

MDLand Enrollment form

Commercial ERA payer list

Blue Cross Blue Shield (Please use Sample PDF below as a guideline to fill in this page. Please DO NOT fill in the PDF.) 

Sample PDF for BCBS


Immunization Registry Form

Please follow the instructions below for the appropriate State/City:

New Jersey:

For both New and Existing Providers: Please complete the new Interface Enrollment Request Form by clicking HERE.  


Vendor Name: MDLAND

Software Name: iClinic

Contact Last Name: Puccio

Contact First Name: Chris

Phone Number: 212-363-8000 ext 121


Interface Type: File Upload

Purpose of Enrollment: Both

File Format/Version: HL7 2.5.1

Press the "SUBMIT" button when complete.

New York City:

Click to Download NYC CIR Confidentiality Statement

Meaningful Use Resources

DIY HIT Security Risk Assessment Questionnaire