Loading
Get Ny Doh-4402 2012-2025
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 NY DOH-4402 online
The NY DOH-4402 form is crucial for payors whose status has changed. This guide will provide you with step-by-step instructions to complete the form accurately and effectively online.
Follow the steps to complete the NY DOH-4402 form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the effective date of the change in the designated field. This date specifies when the status change takes effect.
- Fill in the payor information, including the payor name, federal employer identification number (FEIN), contact person’s name, and phone number.
- In Section I, check the applicable box for your status change. The options include self-insured to fully insured, closed/out of business, bankrupt, or other. Note that the 'other' section should not be used for changes related to third-party administrators or similar situations.
- If a third-party administrator or administrative services only were utilized, please provide their name in the specified field.
- Check either box #1 if reports will continue to be filed for unadjudicated claims, or box #2 to indicate that all claims have been adjudicated. If you check box #2, fill in the effective date for claim adjudication.
- In the comments section, provide a detailed explanation for status changes if you have selected 'bankruptcy' or 'other.'
- If this form is being used to update a previous Payor Status Change (DOH-4402), complete Section II with the final adjudication date, and list any third-party administrator's name if applicable.
- Ensure that an authorized individual from the company signs and dates the form in the signature section.
- Once all fields are completed, save your changes. You can then download, print, or share the form as necessary.
Complete your NY DOH-4402 document online today for a seamless filing experience.
Getting a certificate of authority in New York usually takes about two to four weeks, depending on the volume of applications being processed. If you apply correctly and submit all required documents, you can help expedite the process. Consider utilizing US Legal Forms to ensure your application aligns with the standards outlined in the NY DOH-4402.
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.