Home
Forms Library
DOH-4400 - New York State Department of Health - health ny

DOH-4400 - New York State Department of Health - health ny-2025

DOH-4400 - New York State Department of Health - health ny Preview on Page 1

See details

4.1 out of 5

51 votes

The document is an application form for Third Party Administrators (TPA) or Administrative Services Only (ASO) to elect to make public goods payments directly to the New York State Department of Health's Office of Pool Administration. It outlines the necessary information required for the application, including effective date, Federal Employer Identification Number (FEIN), contact details, and obligations regarding payment remittance and reporting. The document also specifies procedures for identifying electing versus non-electing clients and includes instructions for submitting the completed forms.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

The easiest way to edit DOH-4400 - New York State Department of Health - health ny in PDF format online

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Adjusting paperwork with our comprehensive and intuitive PDF editor is simple. Follow the instructions below to fill out DOH-4400 - New York State Department of Health - health ny online quickly and easily:

Sign in to your account. Log in with your credentials or register a free account to test the product before choosing the subscription.
Import a form. Drag and drop the file from your device or add it from other services, like Google Drive, OneDrive, Dropbox, or an external link.
Edit DOH-4400 - New York State Department of Health - health ny. Easily add and underline text, insert pictures, checkmarks, and symbols, drop new fillable fields, and rearrange or remove pages from your paperwork.
Get the DOH-4400 - New York State Department of Health - health ny completed. Download your adjusted document, export it to the cloud, print it from the editor, or share it with others via a Shareable link or as an email attachment.

Benefit from DocHub, one of the most easy-to-use editors to rapidly handle your paperwork online!

See more DOH-4400 - New York State Department of Health - health ny versions

We've got more versions of the DOH-4400 - New York State Department of Health - health ny form. Select the right DOH-4400 - New York State Department of Health - health ny version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2012	4.1 Satisfied (51 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I update my income on HealthCare gov?

Update your application online Log in to your HealthCare.gov account. Choose the application you want to update. Click Report a Life Change on the left-hand menu. Read through the list of changes, and click Report a Life Change to get started. Select the kind of change you want to report.

How do I report a change in income for Medi-Cal?

For Medi-Cal, you must report it within 10 days. To report changes, call Covered California at (800) 300-1506 or sign in to your online account.

What is the phone number for the New York State Department of Health?

1-800-663-6114 - Complaints/Inquiries (Monday-Friday 9:00 a.m - 5:00 p.m.)

How do I renew my NY State of Health?

Renew Over the Phone 1-855-355-5777 (TTY: 1-800-662-1220). The Customer Service Center is open Monday through Friday from 8:00 AM to 8:00 PM and on Saturday from 9:00 AM to 1:00 PM.

How do I prove my income to NY State of Health?

PROOF OF CURRENT INCOME, OR INCOME YOU MIGHT GET IN THE FUTURE LIKE UNEMPLOYMENT BENEFITS OR A LAWSUIT: You must provide a letter, written statement, or copy of check or stubs, from the employer, person or agency providing the income.

How to update income on NY State of Health?

Reporting Changes Log into your NY State of Health account at nystateofhealth.ny.gov. Meet with an enrollment assistor to receive assistance with updating your account. Call the NY State of Health Customer Service Center at 1-855-355-5777 (TTY: 1-800-662-1220).

How do I update my income for New York State of Health?

Meet with an enrollment assistor to receive assistance with updating your account. Call the NY State of Health Customer Service Center at 1-855-355-5777 (TTY: 1-800-662-1220).

What does the New York State Department of Health do?

The New York State Department of Health (State DOH) protects, improves, and promotes the health, productivity, public safety, and wellbeing of all New Yorkers.

DOH-4400 - New York State Department of Health - health ny-2025

Here's how it works

The easiest way to edit DOH-4400 - New York State Department of Health - health ny in PDF format online

See more DOH-4400 - New York State Department of Health - health ny versions

Complete this form in 5 minutes or less

Got questions?

How do I update my income on HealthCare gov?

How do I report a change in income for Medi-Cal?

What is the phone number for the New York State Department of Health?

How do I renew my NY State of Health?

How do I prove my income to NY State of Health?

Complete this form in 5 minutes or less

People also ask

How to update income on NY State of Health?

How do I update my income for New York State of Health?

What does the New York State Department of Health do?

Related links

Try more PDF tools

DOH-4400 - New York State Department of Health - health ny-2025

Here's how it works

The easiest way to edit DOH-4400 - New York State Department of Health - health ny in PDF format online

See more DOH-4400 - New York State Department of Health - health ny versions

Complete this form in 5 minutes or less

Got questions?

How do I update my income on HealthCare gov?

How do I report a change in income for Medi-Cal?

What is the phone number for the New York State Department of Health?

How do I renew my NY State of Health?

How do I prove my income to NY State of Health?

Related Searches

Related forms

Complete this form in 5 minutes or less

People also ask

How to update income on NY State of Health?

How do I update my income for New York State of Health?

What does the New York State Department of Health do?

Related links

Try more PDF tools