Elector Information, Forms and Instructions

Payor

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

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

Filing Options

Note: These forms are only available during the open enrollment period (November 1 through December 31)

  1. DOH–4486 – Payor Change of Filing Status from Annual to Monthly
    Annual filers may switch to be monthly filers for the upcoming calendar year.
  2. DOH–4459 – End of Month Covered Lives Enrollment Option
    Monthly filers have the option of establishing their covered lives enrollment obligations as of the last day of the month.

Note: For immediate enrollment, Payors with a User ID and Password may file these options electronically through the Payor Options section located on the New York State Office of Pool Administration's web site: www.hcrapools.org/hcra_index.cfm.
If you do not have a User ID and Password you must submit hardcopy form(s) and wait for confirmation of enrollment.