Follow the steps to successfully complete the application.

1. Press the ‘Get Form’ button to access the application form and open it for online editing.
2. Begin by filling out Section A with the corporate name of the applicant and any previously reported name if applicable.
3. In Section B, enter the name and title of the Chief Executive Officer along with their contact information, including street address, city, state, phone number, and email.
4. If applicable, complete Section C with the name and contact information of a different contact person.
5. In Section D, indicate tax status and provide the Federal Employer ID Number. Attach necessary documentation such as the Certificate of Incorporation and the corporate organization chart.
6. Section E requires you to check appropriate options indicating the utilization review services provided. Specify any functions your agency will perform.
7. Continue in Section F to confirm compliance with utilization review requirements and compile all necessary documentation.
8. In Section G, ensure all reviews and determinations adhere to relevant timeframes and standards. Attach any template notices as required.
9. Finally, Section H includes a signature line for the Chief Executive Officer to attest to the accuracy of the application, followed by the date.
10. Once all sections are completed, save changes, download the form, or share it electronically. Ensure that the attestation section is submitted in PDF format.

Complete your NY DFS Utilization Review Agent Report Application and Attestation online today.