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How to fill out the Doh 4409 online
Filling out the Doh 4409 form is an essential task for reporting changes in your payor or third party administrator information. This guide will provide clear and comprehensive instructions to ensure you complete the form accurately and efficiently.
Follow the steps to complete the Doh 4409 form online
- Click 'Get Form' button to retrieve the Doh 4409 form and open it in the designated editor.
- Begin by checking the applicable box that identifies your role: Payor, TPA, or ASO. This helps clarify the information relevant to your organization.
- In the 'Current Information' section, enter your current Federal Employee Identification Number (FEIN), name, address, and contact details accurately.
- Proceed to the 'New Information' section and provide any new FEIN, name, address, and contact information that reflects the changes you are reporting.
- If the name or FEIN change is due to a merger or acquisition, ensure to provide necessary comments in the comments section and refer to the DOH-4406 form as applicable.
- Review all information for accuracy and completeness. Ensure that the details match your organization’s records.
- Sign the form in the designated area, provide your title, phone number, email address, and include today's date.
- Once you have filled out the form, save your changes, then download, print, or share the completed form as needed.
- Mail the completed form to Mr. Jerome Alaimo, Pool Administrator, at the specified address provided at the bottom of the form.
Start completing your Doh 4409 form online today to ensure your records are up-to-date.
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