Ny doh4402 public latest 2026

1. Click ‘Get Form’ to open the ny doh4402 in the editor.
2. Enter the effective date of change at the top of the form. This is crucial for documenting when your payor status changed.
3. Fill in your payor information, including name, federal employer identification number (FEIN), contact person, and phone number.
4. In Section I, check the applicable box that reflects your status change: self-insured to fully insured, closed/out of business, bankrupt, or other. If you select 'other', provide a detailed explanation in the comments section.
5. If a third-party administrator (TPA) or administrative services only (ASO) was utilized, include their name in the designated field.
6. Check either box #1 or box #2 regarding claims adjudication and fill in any necessary dates.
7. Complete Section II only if updating a previously submitted form to indicate a final adjudication date. Again, include TPA/ASO name if applicable.
8. Ensure an authorized individual from your company signs and dates the form before submission.

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