Elector Information, Forms and Instructions

Payor

  • DOH-4402 Payor Status Change (PDF, 40KB, 2pg.)
  • DOH-4403 TPA/ASO Status Change (PDF, 33KB, 2pg.)
  • DOH-4404 Request to Rescind Election Status (PDF, 31KB, 3pg.)
  • DOH-4406 Merger-Acquisition (PDF, 40KB, 2pg.)
  • DOH-4409 Payor/TPA/ASO Change of Information (PDF, 30KB, 1pg.)
  • DOH-4399 Payor Election Application (PDF, 144KB, 7pg.) and DOH-4264 Electronic Filing User ID Application (PDF, 37KB, 2pg.)

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

  • DOH-4401 TPA/ASO Client List Addendum - Additions (PDF, 31KB, 2pg.)
  • DOH-4411 TPA/ASO Client List Addendum - Deletions (PDF, 32KB, 2pg.)
  • DOH-4404 Request to Rescind Election Status (PDF, 57KB, 3pg.)
  • DOH-4409 Payor/TPA/ASO Change of Information (PDF, 30KB, 1pg.)
  • DOH-4400 TPA/ASO Election Application (PDF, 72KB, 6pg) 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.