Get Ny Doh-4399 2012-2026

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.

1. Press the ‘Get Form’ button to download the NY DOH-4399 form and open it in your preferred editing tool.
2. 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.
3. 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.
4. Fill in the 'Payor Name' section with the legal name of the payor, which refers to the incorporated entity or governing body.
5. If applicable, include any 'D/B/As' (doing business as) names under which the payor operates.
6. Enter the complete 'Address' of the payor.
7. Provide the name of the 'Contact Person' who will be responsible for further communication regarding the election.
8. Input the 'Phone #' of the contact person for any follow-up questions or clarifications.
9. Fill in the 'E-Mail Address' of the contact person to facilitate electronic communication.
10. 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.
11. The 'Signature' field must be completed by the chief financial officer or another authorized individual, certifying the payor's commitment to the stated obligations.
12. 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.