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How to fill out the Doh 4264 online
The Doh 4264 form is essential for organizations seeking to establish an electronic filing account for the Public Goods Pool. This guide will provide you with step-by-step instructions to help you efficiently complete the form online.
Follow the steps to successfully fill out the Doh 4264 form online.
- Click the ‘Get Form’ button to access the Doh 4264 form and open it in the editor.
- Indicate whether you are submitting a new request for an account or if you are revising an existing account by checking the appropriate box.
- Enter the name of your organization in the 'Payor/TPA/ASO/Provider Name' field.
- Input the Federal Employer Identification Number (FEIN) assigned to your organization.
- If applicable, provide the Operating Certificate number assigned by the Department of Health for your organization.
- Check all relevant types of reports you will be filing electronically: Public Goods Pool and/or 1% Statewide Assessment.
- Ensure that the form is signed by the Chief Executive, Chief Financial Officer, or Administrator of your organization.
- Print the name, title, and phone number of the individual who signed the form.
- Fill out the address, city, state, and zip code for the person who signed.
- Provide the email address that will be used for communication regarding Health Care Reform Act information.
- Enter the date on which the form is signed.
- After completing the form, save your changes, download, print, or share the completed Doh 4264 as needed.
Start filling out the Doh 4264 form online today to ensure you meet your electronic filing requirements.
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