Get Doh 4264

The Doh 4264 form is a critical application for establishing an electronic filing user ID for the Health Care Reform Act's Public Goods Pool. This guide provides clear instructions to help users complete the form smoothly, ensuring accurate submission.

Follow the steps to fill out the Doh 4264 online effectively.

1. Click the ‘Get Form’ button to acquire the form. After pressing the button, the form will open for you to complete online.
2. Indicate whether you are submitting a New Request or a Revision to Existing Account by checking the appropriate box at the top of the form.
3. Enter the name of the payor, third party administrator, administrative services only organization, or provider in the designated field.
4. Input the Federal Employer Identification Number (FEIN) assigned to the entity in the specified space below the name.
5. For providers, enter the Operating Certificate number assigned by the Department of Health in the next field.
6. Check all applicable types of reports that your entity will be filing electronically, specifically the Public Goods Pool and/or 1% Statewide Assessment.
7. Ensure the form is signed by the Chief Executive, Chief Financial Officer, or Administrator designated by your entity.
8. Provide the name, title, and phone number of the signer as clearly indicated in the provided fields.
9. Fill in the address, city, state, and zip code of the signer to ensure proper communication.
10. Enter the email address of the signer, which will be vital for receiving updates and communications regarding the Health Care Reform Act.
11. Finally, input the date the form is signed to complete the application.
12. After completing the form, you can save any changes made, download a copy for your records, print the completed form, or share it as needed.

Start filling out the Doh 4264 online to ensure compliance with the Health Care Reform Act.