EP Meaningful Use (MU)

NY Medicaid EHR Incentive Program
Attestation Deadline Extension (ADE) Request Form

This form is used to request an attestation deadline extension by providing evidence that extenuating circumstances beyond the provider´s control prevented the provider from attesting in MEIPASS by the attestation deadline. The ADE Request Form must be completed in its entirety and submitted to attestation@health.ny.gov to be formally considered for an extension for Payment Year 2020 by the NY Medicaid EHR Incentive Program.
Provider Name:
Provider Email:
CMS Registration ID
Provider NPI:
Organization NPI (If Applicable):
Payment Year
Extension Request Justification