Doh 4264-2026

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4.8 out of 5

302 votes

The document outlines the process for obtaining an Electronic Filing User ID for the Health Care Reform Act's Public Goods Pool in New York State. It details the requirements for payors, third-party administrators, and providers to file reports electronically, including the need for a secure account and password. The document provides instructions on completing the application form (DOH-4264), including necessary information such as entity name, Federal Employer Identification Number, and contact details. It also mentions available assistance through a help desk.

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

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

What is New York HCRA surcharge?

Payor Status Change. HEALTH CARE REFORM ACT PUBLIC GOODS POOL. This form is to be completed to reflect the following status changes: self-insured to fully insured; closed/out of business; bankrupt; or other.

What is NY HCRA?

HCRA is a major component of New York States Health Care financing laws which governs hospital reimbursement methodologies and targets funding for a multitude of health care initiatives.

What is DOH 4264?

Upon receipt of a fully completed Electronic Filing User ID Application (DOH-4264), the Office of Pool Administration will assign a secure electronic filing user ID and password to your organization, which you will receive via return mail. New Request/Revision to Existing Account: Check the appropriate box.