New York State Health Care Reform Act (HCRA)

Public Goods Pool

Provider Information, Forms and Instructions

  • 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-4408 Provider Status Change (i.e., merged with another provider, ceased doing business) (PDF, 38KB, 2pg.)

Note: If you are a provider that has had a name or address change not related to a merger, you must notify your Regional New York State Department of Health. If the change is a result of a merger, you must also complete form DOH-4408 (Provider Status Change)