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 Doh 4402 2012-2023

Doh 4402 2012-2023

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Information: Enter payor name, federal employer identification number (FEIN), contact, and phone #. SECTION I: Check applicable box: Check appropriate box to reflect the following status changes: self-insured to fully insured; closed/out of business; bankrupt; or other. The section “other” is not to be completed to reflect a status change resulting from a change in third-party administrator (TPA)/administrative services only (ASO), rescission, or merger. If a TPA/ASO was utilized, provide...
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