Doh 4264-2026

1. Click ‘Get Form’ to open the DOH-4264 in the editor.
2. Select whether you are making a New Request or a Revision to an Existing Account by checking the appropriate box at the top of the form.
3. In the 'Payor/TPA/ASO/Provider Name' field, enter the name of your organization that will be using the OPA website.
4. Provide your Federal Employer Identification Number (FEIN) in the designated field.
5. If applicable, enter your Operating Certificate number assigned by the Department of Health.
6. Check all applicable report types you will be filing electronically, including Public Goods Pool and/or Statewide Assessment.
7. Ensure that the form is signed by an authorized individual, such as the Chief Executive or Financial Officer.
8. Fill in the signer’s name, title, phone number, address, email address, and date of signing.
9. Once completed, save your changes and submit the form as instructed at the bottom of the document.

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