Elector Information, Forms and Instructions


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)

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.
If you do not have a User ID and Password you must submit hardcopy form(s) and wait for confirmation of enrollment.