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Doh 4403 form-2026
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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 at the top of the form.
- 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 'Additional TPA/ASO' or 'Changing TPA/ASO'.
- If applicable, provide previous TPA/ASO information by entering their name and FEIN.
- For new or additional TPA/ASO details, enter their name, FEIN, address, contact person, and phone number.
- Check one of the options regarding claims run out based on your situation.
- An authorized individual must sign and date the form in the signature section before submission.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2012 | 4.9 Satisfied (345 Votes) |
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