New York State

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Health Care Reform Act

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You are Here: Home Page > Health Care Reform Act (HCRA) > New York State Health Care Reform Act (HCRA)  

New York State Health Care Reform Act (HCRA)

• Cross-Reference Index for HCRA Forms (PDF, 23KB, 1pg.)
• Reporting Forms and Instructions

Payor

• DOH-4399 Payor Election Application (PDF, 80KB, 7pg.) and DOH-4264 Electronic Filing User ID Application (PDF, 37KB, 2pg.)
• DOH-4402 Payor Status Change (PDF, 40KB, 2pg.)
• DOH-4403 TPA/ASO Status Change (PDF, 33KB, 2pg.)
• DOH-4404 Request to Rescind Election Status (PDF, 43KB, 2pg.)
• DOH-4406 Merger-Acquisition (PDF, 40KB, 2pg.)
• DOH-4409 Payor/TPA/ASO Change of Information (PDF, 30KB, 1pg.)

Third Party Administrator (TPA)/Adminstrative Services Only (ASO)

• DOH-4400 TPA/ASO Election Application (PDF, 50KB, 6pg) and DOH-4264 Electronic Filing User ID Application (PDF, 37KB, 2pg.)
• DOH-4401 TPA/ASO Client List Addendum - Additions (PDF, 31KB, 2pg.)
• DOH-4411 TPA/ASO Client List Addendum - Deletions (PDF, 32KB, 2pg.)
• DOH-4404 Request to Rescind Election Status (PDF, 43KB, 2pg.)
• DOH-4409 Payor/TPA/ASO Change of Information (PDF, 30KB, 1pg.)

Provider

• DOH-4405 Provider Election For Medicaid Withholding (PDF, 26KB, 1pg.) or Report of Medical Assistance Surcharge Payments for Non-Electing Providers (PDF, 38KB, 3pg.)
• DOH-4264 Electronic Filing User ID Application (PDF, 37KB, 2pg.)
• DOH-4407 Provider Name and Address Change (PDF, 26KB, 1pg.)
• DOH-4408 Provider Status Change (PDF, 38KB, 2pg.)