Form DOH-4405 Provider Election Form for Medicaid Withholding - New York

What Is Form DOH-4405?

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.

Form Details:

• Released on February 1, 2012;
• The latest edition provided by the New York State Department of Health;
• Easy to use and ready to print;
• Quick to customize;
• Compatible with most PDF-viewing applications;
• Fill out the form in our online filing application.

Download a printable version of Form DOH-4405 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.