Get Doh 4406

Filling out the Doh 4406 form is an important step in the merger and acquisition process for healthcare entities. This guide will walk you through each section of the form, providing the clarity and support needed to complete it correctly.

Follow the steps to fill out the Doh 4406 form accurately.

1. Press the ‘Get Form’ button to access the form and open it in the online editor.
2. Enter the legal name of the acquiring company along with its federal employer identification number (FEIN). If applicable, also include the name and FEIN of the corresponding health plan.
3. Input the legal name of the acquired company and its FEIN. Again, if the health plan's information differs, provide that as well.
4. Specify the effective date of the merger or acquisition by entering the correct date in the designated field.
5. Indicate whether the health plan terminated on the effective date by checking 'yes' or 'no'. If 'no', enter the termination date of the health plan.
6. State the name of the company responsible for any outstanding health plan obligations that may exist up to the date the health plan terminated.
7. Enter the name of the company responsible for paying run-out claims for the plan, avoiding third-party administrators (TPA) or administrative services only (ASO) entities.
8. Record the date by which all New York claims were adjudicated.
9. Indicate whether the acquiring company is a participant as an elector in the NYS Public Goods Pool by checking the appropriate box.
10. If the acquiring company is not a participant, select whether they wish to become one.
11. Add any comments or additional information regarding the merger or acquisition in the comments section provided.
12. Ensure that an authorized individual from the company signs and dates the form in the signature section.
13. Finally, review the completed form and save changes, download, print, or share it as needed.

Take the first step and complete your Doh 4406 form online today.