to make public goods payments directly to the Office of Pool Administration must complete forms DOH-4399 (Payor Election Application) and DOH-4264 (Electronic Filing User ID Application). Instructions for pages 1 and 2: Effective Date: Enter effective date of election. Note: An election application received from any payor or organization shall begin on the first day of the month following the date it was received by the Office of Pool Administration unless a future date is specified. Federal Em.
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How to fill out the NY DOH-4399 online
The NY DOH-4399 form is essential for payors electing to make public goods payments directly to the Office of Pool Administration. This guide offers step-by-step instructions to assist users in accurately completing the form online.
Follow the steps to successfully fill out the NY DOH-4399 form.
- Press the ‘Get Form’ button to download the NY DOH-4399 form and open it in your preferred editing tool.
- In the 'Effective Date' field, enter the date when the election will become effective. Note that the election will commence on the first day of the month following receipt, unless a future date is indicated.
- In the 'Federal Employer Identification # (FEIN)' field, input the FEIN of the payor, as this information will be published on a secure site as mandated by law.
- Fill in the 'Payor Name' section with the legal name of the payor, which refers to the incorporated entity or governing body.
- If applicable, include any 'D/B/As' (doing business as) names under which the payor operates.
- Enter the complete 'Address' of the payor.
- Provide the name of the 'Contact Person' who will be responsible for further communication regarding the election.
- Input the 'Phone #' of the contact person for any follow-up questions or clarifications.
- Fill in the 'E-Mail Address' of the contact person to facilitate electronic communication.
- If a third-party administrator (TPA) or administrative services only (ASO) is used, provide their name and FEIN. If there are multiple TPAs/ASOs, you may need to attach additional documentation.
- The 'Signature' field must be completed by the chief financial officer or another authorized individual, certifying the payor's commitment to the stated obligations.
- Finally, save your changes and choose to download, print, or share the fully completed form as needed.
Complete your NY DOH-4399 form online to ensure compliance and timely submission.
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What is doh 4399?
DOH-4399 INSTRUCTIONS A payor voluntarily electing to make public goods payments directly to the Office of Pool Administration must complete forms DOH-4399 (Payor Election Application) and DOH-4264 (Electronic Filing User ID Application).
What is the New York Public Goods pool?
State of New York Health Care Reform Act – Public Goods Pool. The New York Health Care Reform Act (NYHCRA) imposes certain surcharges and assessments on a variety of health care physician/other health care professional services received in New York state by a covered member.
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