Self-Disclosure Abbreviated Statement

This form is required for the reporting and explaining of voids and adjustments where the error was routine or transactional in nature. Providers are required to report, return and explain any overpayments they’ve received to the New York State Office of the Medicaid Inspector General (OMIG) Self-Disclosure Program within sixty (60) days of identification, or by the date any corresponding cost report was due, whichever is later. See Social Services Law (SOS) §363-d(6).

If you have any questions regarding this form, please email selfdisclosures@omig.ny.gov.

By completing and submitting this form you are attesting that all of the information provided is accurate. All fields are required to be completed.

Required spreadsheet file

* Required field

Provider Information

Federal Employer Identification Number (FEIN) or Social Security Number (SSN):
Please use whichever identifier is used on your 1099 Tax Form (no dashes)

Re-Enter FEIN or Social Security Number (SSN):

Provider Name (or DBA):

Address:

City:

State:

Zip Code:

Contact Information

First Name:

Last Name:

Title:

Phone Number:
(including area code)

Email Address:

Re-Enter Email Address:

Disclosure Data

Upload the completed spreadsheet file.
Note: If you have not yet done so, please download the spreadsheet via the link at the top of this page. When the spreadsheet is complete, please use the button below to upload it.

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Self-Disclosure Abbreviated Statement