Loading
Get Doh 4459 Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Doh 4459 Form online
The Doh 4459 Form is an essential document for payors electing the end-of-month covered lives enrollment option. This guide provides clear instructions to assist you in accurately completing this form online, ensuring compliance with New York State Department of Health requirements.
Follow the steps to complete the Doh 4459 Form online.
- Click ‘Get Form’ button to obtain the form and open it in your chosen online editor.
- Enter the effective date by inputting the calendar year for which the enrollment option will be applicable (e.g., 2009, 2010).
- Input the Federal Employer Identification Number used by the Payor in the designated field.
- Fill in the name of the payor in the Payor Name section clearly and accurately.
- Provide the payor's complete address in the Address section.
- In the Contact Person field, print the name of the authorized individual responsible for signing the form.
- Have the authorized individual sign the form in the Signature section.
- Input the title of the authorized individual in the Title section.
- Enter the phone number of the contact person in the Phone field.
- Clearly print the email address of the contact person in the E-Mail Address field.
- Finally, input the date on which this form was signed.
- Review all entries for accuracy before saving changes, downloading, printing, or sharing the completed form as required.
Complete your Doh 4459 Form online today to ensure compliance with enrollment options.
To file form 9A, you need to source the correct form version and gather supporting documentation. Carefully fill out all required fields to ensure you meet submission criteria. Once completed, submit the form through the designated channels. UsLegalForms can offer the assistance you need to navigate this filing process smoothly.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.