N.Y. Comp. Codes R. & Regs. tit. 18, § 542.4 – Notice of subrogation to liable third parties.

(a) If a provider submits a claim for reimbursement to a liable third party as an agent of the department, such liable third party is directed to make payment to the provider submitting the claim. Such provider is authorized to submit with, or notate upon, its claim the following statement:
“This claim is submitted by a medical assistance provider as an agent of the New York State Department of Social Services in accordance with 18 NYCRR Part 542 and any payment due to the Department must be made to the provider submitting this claim.”
(b) Instead of submitting the notice described in subdivision (a) of this section, a provider may submit with its claim any form supplied or prescribed by the department, a social services district or a social services official which indicates that the provider is acting as agent for the department, a social services district or a social services official.