Get New York Instructions For Completion Of Hmopshp Certification Application Form

This guide provides a clear and supportive overview of how to accurately fill out the New York Instructions For Completion Of Hmopshp Certification Application Form online. By following the steps outlined, users can ensure they complete the form correctly and efficiently.

Follow the steps to successfully complete the application form.

1. Click ‘Get Form’ button to access the certification application form online and open it in your preferred interface.
2. Begin by filling out the identifying information required for the proposed HMO/PHSP. Include the name of the proposed HMO/PSHP and the name of the individual or entity under review.
3. Provide the dates of affiliation in the format MM/DD/YYYY for both the start and end dates of the health care operation that will be reported on.
4. Indicate the type of health care operation and provide the full name and address of the operation in the designated fields.
5. Fill out the regulatory agency section. Include the name of the person replying, their title, telephone number, and office name/address along with the city, state, and zip code.
6. Answer the compliance questions regarding the health care operation during the stated period by selecting 'Yes' or 'No'. If 'No', provide further explanation as needed.
7. Address any concerns that regulators may have regarding the management or performance of the health care operation by marking 'Yes' or 'No', and include explanations where applicable.
8. Lastly, confirm any concerns related to the quality of health care provided by the operation. Again, note 'Yes' or 'No' and provide explanations if necessary.
9. Add any additional comments in the space provided on the back of the form.
10. Finally, ensure you provide your signature, date the form, and review all information before concluding the process. Save changes, download, print, or share the completed form as necessary.

Start filling out the New York Instructions For Completion Of Hmopshp Certification Application Form online today.