Form DOH-4405 Provider Election Form for Medicaid Withholding - New York

Form DOH-4405 Provider Election Form for Medicaid Withholding - New York

What Is Form DOH-4405?

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 February 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-4405 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-4405 Provider Election Form for Medicaid Withholding - New York

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  • Form DOH-4405 Provider Election Form for Medicaid Withholding - New York, Page 1
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