In the landscape of health care regulation in New York State, the Utilization Review Agent Registration Application and Attestation, known as the DOH 4291A form, plays a significant role. Managed by the Office of Managed Care within the New York State Department of Health, this form stands as a required gateway for entities aiming to operate as Utilization Review Agents. Its broader purpose aligns with the oversight of health care management, ensuring that companies involved in the assessment and approval of treatment plans adhere to established standards. Applicants, typically represented by their Chief Executive Officers, must declare their operational details — from their tax status to the physical address of their business. This declaration extends into a commitment, made under penalty of perjury, that all information provided is accurate and truthful. Furthermore, the form differentiates between new applications and re-registrations, the latter of which requires attestation that no changes have occurred since the previous submission, or if there have been changes, that they are accurately reflected in the current application. Coupled with the accompanying DOH-4291B form, which serves as a summary checklist, the DOH 4291A form embodies a crucial step in the process of maintaining the integrity and quality of managed care services within the state.
| Question | Answer |
|---|---|
| Form Name | Doh 4291A Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | agent application form template, online agent application, agent registration form pdf, agent recruitment form |
NEW YORK STATE DEPARTMENT OF HEALTH Office of Managed Care
Bureau of Managed Care Certification and Surveillance
Utilization Review Agent Registration Application and Attestation
Complete and sign this form. Submit with completed Utilization Review Registration Application Summary/Checklist
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Name of Applicant:
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TAX STATUS |
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Federal Employer ID Number:
Attestation:
I, _____________________________________________________________ (Chief Executive
Officer) subscribe and affirm as true, under penalty of perjury,
the information included in this Article 49 application and reported to the New York State Department of Health.
there are no changes to the Article 49 application as reported to the New York State Department of Health on ___________________.
(date)
the information included in this Article 49 renewal application and reported to the New York State Department of Health as amending the Article 49 application reported to the New York State Department of Health on ___________________.
(date)
Signature:
Date: