Public Goods Pool Reporting Forms and Instructions

NOTE: The annual Public Goods Pool reporting forms may only be used by electing payors (and electing TPAs submitting reports on behalf of such payors) that have been notified by the Department that their organization meets the criteria for filing an annual Public Goods Pool report and payment for the current reporting year and that did not timely submit the supplied form to the Pool Administrator to change their organization's filing designation from annual to monthly.

Annual Payor/TPA Pool Reporting Forms and Instructions

  • Instructions for Completing Report Forms (PDF, 61KB)

    NOTE: Updated instructions for reporting periods beginning April 1, 2009 are located at: http://www.health.state.ny.us/nysdoh/hcra/rfmenu.htm

  • Report Forms - The Reporting Forms are only available in PDF. If you need these documents in an alternate format, please call (518) 474-1673.

    NOTE: Both the Patient Services Payments and Surcharge Obligations and the Covered Lives Assessments forms have to be filed for the appropriate service years

    • Patient Services Payments and Surcharge Obligations
    • Covered Lives Assessments