Form Doh 4405 is an important form that businesses must file in order to claim certain tax credits. This form, which is also known as the Research and Experimentation Tax Credit Form, allows businesses to receive a credit for specific research and development expenses. Filing this form correctly can help your business save money on its taxes, so it's important to know what qualifies for the credit and how to complete the paperwork correctly. In this blog post, we'll walk you through everything you need to know about Form Doh 4405 so that you can claim the credit for your business' research and development expenses.
| Question | Answer |
|---|---|
| Form Name | Form Doh 4405 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | doh 4405 excellus blue cross blue shield new york state surcharge payment form |
NEW YORK STATE DEPARTMENT OF HEALTH Division of Finance and Rate Setting
Provider Election Form for Medicaid Surcharge Withholding
HEALTH CARE REFORM ACT – PUBLIC GOODS POOL
Mr. Jerome Alaimo, Pool Administrator
Office of Pool Administration
Excellus BlueCross BlueShield
Central New York Region
P.O. Box 4757
Syracuse, New York
Dear Mr. Alaimo:
Re: New York State Health Care Reform Act (HCRA) Medicaid Surcharge Payments
Pursuant to Section
This election, once processed, becomes effective immediately and will remain in effect (pursuant to authorizing statute) unless written revocation is received by the Office of Pool Administration postmarked no later than December 1 in the year immediately preceding the next calendar year.
________________________________________________ |
_______________________ |
Signature - CFO/Controller |
Date |
FEDERAL TAX |
OPERATING |
IDENTIFICATION #: _________________________ |
CERTIFICATE #: _____________________ |
PROVIDER ID: ______________________________ |
NPI: ________________________________ |
(Medicaid Provider ID) |
(Entity National Provider Identifier) |
FACILITY NAME: ____________________________________________________________________
ADDRESS: ___________________________________________________________________________
CONTACT PERSON: ___________________________________________________________________
PHONE#: ______________________________
EMAIL ADDRESS: ____________________________________________________________________
DOH