Complete and return to your local BOCES Regional Information Center (RIC)
This application must be completed for each individual who requires access to the NYS Medicaid Reports Website for a specific Medicaid “Provider” (NYS School District or County). Print all information clearly.
Provider Name __________________________________________________________________
Provider Address __________________________________________________________________
Provider Number ____________________ Local BOCES RIC (name) ___________________
Applicant Information
Check One: _____ Provider Employee _____ 3rd Party Contractor Employee
Last Name ______________________ First Name ______________________ MI __
Title _____________________________________________
Phone # _________________ Fax # ______________ Email ________________________
For 3rd Party Contractor only
Company Name: ____________________________________________________________________
Company CEO: ____________________________________________________________________
(The Contractor is responsible for notifying the Provider of the status of the employee submitting this application)
The applicant will be contacted by their Local BOCES RIC via telephone with a user ID and password.
As a user of the Medicaid Reports website (MR Web) hosted by the Central Billing Agency at OCM BOCES, I agree NOT to:
Share my User Profile ID and Password | Destroy or damage other users’ data or programs |
Violate the proprietary rights and copyrights in data and software used for MR Web. | Obtain unauthorized access to a user account and/or use the website for purposes other than those to which I am permitted |
Obtain unauthorized access to the use of an account and/or the website for personal or private gain. | Read or use private files/data without proper authorization. |
Reveal the contents of any database housing personal and confidential information | Attempt, without authorization, to modify computer hardware or system software |
The Central Billing agency reserves the right to disable or remove any Medicaid Reports user account that is found to be in violation of the Acceptable Use Guidelines.
When there is any indication of unauthorized use of the Medicaid Reports website, or any other action which interferes with the proper functioning of the system or infringes on the rights of the other users, the NYS Education Department, OCM BOCES, or other appropriate agency will be authorized to investigate. Unethical or irresponsible use of the system will be referred to the appropriate authorities for disciplinary or legal action. Signatures below must be in blue ink.
Applicant Signature: ________________________________________ Date: _______________
Provider Chief Administrator Name: ________________________________________
Provider Chief Administrator Signature: ________________________________________ Date: _______________
** PLEASE NOTE **
It is the responsibility of the Chief Administrator to notify the Local BOCES RIC upon termination of the services of the above named applicant. Such notification must be made in writing a minimum of 5 business days in advance of the date of termination. The Provider may enter into a contract with any 3rd Party Vendor they choose to create their Medicaid claim. This contract must include language that insures the advance notification of the termination of the applicant indicated above.