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INSTRUCTIONS FOR COMPLETING THE NY MEDICAID ENROLLMENT FORM FOR LICENSED PRACTICAL NURSE / REGISTERED NURSE 1. General Instructions: Complete ALL items on the form unless otherwise instructed below.

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The appropriate 4-digit refers to the specific code or number required to access or input certain information or data.

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Individuals or entities who need to secure access to specific systems or data may be required to file the appropriate 4-digit code.

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