Form DOH-4399 Payor Election Application - New York

What Is Form DOH-4399?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form DOH-4399?
A: Form DOH-4399 is the Payor Election Application in New York.

Q: What is this form used for?
A: This form is used to elect a payor for certain Medicaid-covered services in New York.

Q: Who can use this form?
A: This form can be used by individuals who are eligible for Medicaid in New York and need to choose a payor for their services.

Q: Is there a fee to submit this form?
A: No, there is no fee to submit Form DOH-4399.

Q: What information is required on this form?
A: You will need to provide your personal information, Medicaid information, and the name of the payor you wish to elect.

Q: Can I change my payor after submitting this form?
A: Yes, you can change your payor by submitting a new Payor Election Application.

Q: Is there a deadline to submit this form?
A: There is no specific deadline mentioned for submitting this form, but it is recommended to submit it as soon as possible once you have made your decision.