Form DOH-4411 "Tpa/Aso Client List Addendum - Deletions" - New York

What Is Form DOH-4411?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2012;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOH-4411 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

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Download Form DOH-4411 "Tpa/Aso Client List Addendum - Deletions" - New York

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Third Party Administrators (TPA) or Administrative
NEW YORK STATE DEPARTMENT OF HEALTH
Services Only (ASO) Client List Addendum - Deletions
Division of Finance and Rate Setting
HEALTH CARE REFORM ACT – PUBLIC GOODS POOL
DOH-4411 INSTRUCTIONS
Must be completed by TPA/ASO for electing clients, which are being deleted from the original election
submission filed.
Note: This form is to be utilized only by a TPA/ASO and acts as an addendum to their originally filed election
application in the case where electing clients are no longer represented. This form is not intended to remove
certified electors from the elector list.
The form is to be completed as follows:
TPA/ASO Name: Enter name of TPA/ASO.
TPA/ASO FEIN: Enter FEIN of TPA/ASO.
Contact Person: Enter name of person responsible for providing the Department or providers related
information regarding the elections of a TPA’s/ASO’s represented funds.
Phone #: Enter phone number of the contact person.
Deletions: List each organization and a contact email address that is being deleted from your original election
submission with their FEIN, termination date and contracted claims run-out date. The termination date is the
date the payor is no longer your client.
Please mail completed form to:
Mr. Jerome Alaimo, Pool Administrator
Office of Pool Administration
Excellus BlueCross BlueShield, Central New York Region
P.O. Box 4757
Syracuse, New York 13221-4757
Instructions – Page 1 of 1
Third Party Administrators (TPA) or Administrative
NEW YORK STATE DEPARTMENT OF HEALTH
Services Only (ASO) Client List Addendum - Deletions
Division of Finance and Rate Setting
HEALTH CARE REFORM ACT – PUBLIC GOODS POOL
DOH-4411 INSTRUCTIONS
Must be completed by TPA/ASO for electing clients, which are being deleted from the original election
submission filed.
Note: This form is to be utilized only by a TPA/ASO and acts as an addendum to their originally filed election
application in the case where electing clients are no longer represented. This form is not intended to remove
certified electors from the elector list.
The form is to be completed as follows:
TPA/ASO Name: Enter name of TPA/ASO.
TPA/ASO FEIN: Enter FEIN of TPA/ASO.
Contact Person: Enter name of person responsible for providing the Department or providers related
information regarding the elections of a TPA’s/ASO’s represented funds.
Phone #: Enter phone number of the contact person.
Deletions: List each organization and a contact email address that is being deleted from your original election
submission with their FEIN, termination date and contracted claims run-out date. The termination date is the
date the payor is no longer your client.
Please mail completed form to:
Mr. Jerome Alaimo, Pool Administrator
Office of Pool Administration
Excellus BlueCross BlueShield, Central New York Region
P.O. Box 4757
Syracuse, New York 13221-4757
Instructions – Page 1 of 1
Third Party Administrators (TPA) or Administrative
NEW YORK STATE DEPARTMENT OF HEALTH
Services Only (ASO) Client List Addendum - Deletions
Division of Finance and Rate Setting
HEALTH CARE REFORM ACT – PUBLIC GOODS POOL
Must be completed by TPA/ASO for electing clients, which are being deleted from the original election submission filed.
TPA/ASO Name:________________________________________
TPA/ASO FEIN:______________________
Contact Person:________________________________________
Phone #:_____________________________
DELETIONS:
List those organizations you represent, and are deleting from the original election submission. Attach additional sheets if
necessary.
ORGANIZATION NAME (Legal Name)
CONTRACTED
ORGANIZATION
TERMINATION
&
CLAIMS
FEIN
DATE
ORGANIZATION CONTACT (Email Address)
RUN-OUT DATE
By signature below, the TPA/ASO on behalf of the self-insured clients listed above, certifies that the original election
certification is amended to reflect the terminated funds listed above.
Signature_____________________________________________
Date____________________
DOH –4411 (5/2012) Page 1 of 1
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