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Get and Sign Payor Application  Form

Get and Sign Payor Application Form

Use a doh 4399 template to make your document workflow more streamlined.

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 Employer Identification FEIN Enter federal employer identification number FEIN of the payor. Please note that Section 2807-j 5 a iii D of the Public Health Law requires the New York State Department of Health to...
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