Doh 4403 form-2025

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The document outlines the process for payors in New York State to report a change in their Third Party Administrator (TPA) or Administrative Services Only (ASO) status as part of the Health Care Reform Act. It includes instructions for completing a form that captures details about the effective date of the change, previous and new TPA/ASO information, and necessary signatures. The form must be submitted to the Office of Pool Administration.

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Click ‘Get Form’ to open the doh 4403 form in the editor.
Enter the effective date of the status change in the designated field.
Fill in your payor information, including payor name, federal identification number (FEIN), contact person, and phone number.
Select the type of status change by checking the appropriate box: either adding or changing a TPA/ASO organization.
If applicable, provide previous TPA/ASO information by entering their name and FEIN.
For new or additional TPA/ASO information, enter their name, FEIN, address, contact person, and phone number.
Check one of the options regarding claims run out based on your situation.
Ensure an authorized individual from your company signs and dates the form in the signature section.

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What is a doh form?

This form provides consent for enrollment in a Health Home and for the purpose of. sharing health information for individuals who are 18 years of age or older or are under the age of 18 AND a parent, pregnant, or married.

What is doh 4403?

DOH-4403 INSTRUCTIONS This form is to be completed by a payor whose status has changed from the original election as it relates to whether a TPA/ASO is utilized for claims processing.

What is the rule 4403 in NY?

New York Consolidated Laws, Civil Practice Law and Rules - CVP Rule 4403. Motion for new trial or to confirm or reject or grant other relief after reference to report or verdict of advisory jury.

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