Forms

Requests for applications/forms in an alternate format can be made by sending an e-mail note to dohweb@health.state.ny.us.

Adoption

• Adoptee Registration Form
• Birth Parent Registration Form
• Biological Sibling Registration Form

AIDS Institute

• New York State Condom Program Organization Information and Attestation (OIA) Form
• Uninsured Care Programs Provider/Service Manuals
• Uninsured Care Programs Assurances & Agreements with Enrollment Form
• HIV Uninsured Care Programs Application (English)
• Solicitude para el Programa de Cuidado de VIH (Español)
• Uninsured Care Programs
  • Assignment of Benefits (PDF, 58KB, 1pg.)
  • Addendum to Home Care (PDF, 40KB, 1pg.)
  • Home Health Certification and Plan of Treatment (PDF, 55KB, 1pg.)
  • Nursing Assessment for Home Care (PDF, 86KB, 3pg.)
  • Home Care DME Prior Aproval Request AI-3615 (PDF, 29KB, 1pg.)
• Required HIV Related Consent & Authorization Forms
• Expanded Syringe Access Program (ESAP) Forms
• HIV Counseling & Testing Resource Directory Forms
• HIV/AIDS Educational Materials Order Forms

Americans with Disabilities Act

• Americans with Disabilities Act Complaint Form (PDF, 53KB, 1pg.)

Asbestos

• Application for Asbestos Training Equivalency (DOH-4353) (PDF, 21KB, 2pg)
• Application for Approval or Revision of an Asbestos Safety Training Program (PDF, 26KB, 2pg)

Assisted Living

• Assisted Living

Audit Reporting Requirements

• Audit Reporting Requirements

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Birth, Death, Marriage, Divorce

• Birth Certificates
• Birth Certificate Mail-in Application
• Death Certificates
• Death Certificate Mail-in Application
• Marriage Certificates
• Marriage Certificate Mail-in Aplication
• Divorce Certificates
• Divorce Certificate Mail-in Aplication

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Cash Receipts Assessment Program

• Reporting Forms and Instructions
• User ID Application for Electronic Filing
• Certification Form

Certificate of Need

• Certificate of Need Application

Child and Adult Care Food Program

• Applications and Forms for Participating Day Care Centers
• Applications and Forms for Participating Day Care Homes

Children's Camps

• Children's Camp Facility & Staff Description
• Children's Camp Additional Staff Qualifications
• Children's Camp Written Plan Checklist
• Prospective Children' Camp Director Certified Statement

Communicable Disease

• Communicable Disease Reporting
• Prevent Herpes Transmission During Ritual Circumcision
  • Ordering Brochures

Controlled Substances / Narcotic Enforcement

• Narcotic Enforcement Forms

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Dental

• Oral Health Education and Publications Order Form (PDF 24KB 1pg)
• Request for Prior Approval of Orthodontic and Orthdontia-Related Services

Diabetes

• Diabetes Publications Order Form

Disposition of Remains

• Disposition of Remains

Do Not Resuscitate (DNR) Orders

• Nonhospital Order Not to Resuscitate
• Nonhospital DNR and Do Not Intubate (DNI) Order

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Early Intervention

• Early Intervention Publications Order Form

Emergency Medical Services (EMS)

• Forms Commonly Used by EMS Providers and Agencies

Employment

• Employment Application

Genealogy

• Genealogy Copies
• Genealogy Application

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Health and Safety Outdoors

• General Forms

Health Care Coverage

• Child Health Plus Application
• Elderly Pharmaceutical Insurance Coverage (EPIC)
  • Application for New York Prescription Saver Card
• Family Health Plus
• Family Planning Benefit Program
  • Family Planning Benefit Program Materials Order Form (PDF, 16KB, 1pg.)
• Health Insurance and Nutrition Application for Children, Adults, and Families
• Healthy New York Program
• HIV Uninsured Care Programs
• Medicaid
• Medicaid Obstetrical and Maternal Services (MOMS) Program
• Prenatal Care Assistance Program (PCAP)
• Women, Infants and Children (WIC) Nutritional Program
  • Forms for Health Care Providers
    • Information for Health Care Providers
  • Day Care Centers/Homes
    • Certificate of Authority Form (PDF, 58.2KB, 1pg)

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Health Care Proxy

• Health Care Proxy Form Order Form
• Health Care Proxy Form

Health Care Reform Act (HCRA)

• HCRA Forms

Health Facilities Cash Assessment Program (HFCAP)

• User ID Application for Electronic Filing
  • Home Care Agencies (CHHA, LTHHCP and PCP)
  • Hospitals
  • Residential Health Care Facility (RHCF)

Helen Hayes Hospital

• Employment Application Form (PDF, 68KB, 2pg.)
• Volunteer Corps Application Form (PDF, 116KB,1pg.)
• Founders Fund Enrollment Form
• MacArthur Park Order Form
• TLC Learning Center Application/Wait List Form (PDF, 89KB, 1pg.)

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HIV/AIDS

• HIV/AIDS Forms
• Opioid Overdose Prevention Program Registration (PDF, 52 KB, 2pg.)

Home Care Services Agencies

• Criminal History Record Check Request Form

Hospital and Primary Care Services

• Complaint Form

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Immunization

• Influenza Vaccine (DOH-4482) (PDF, 83KB, 1pg.)
• Instructions for Completing the Seasonal Influenza and Pneumococcal Immunization Data Report for Long Term Care Facilities

Infection Control

• Infection Control Training Forms
• Infection Control Reporting Forms

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Lead Poisoning Prevention Education Materials

• Lead Poisoning Prevention Education Materials (PDF, 42KB, 2pg.)

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Managed Care

• Division of Managed Care Forms

Medicaid

• Obtaining Medicaid Payment Records

Medicaid Provider (NYS)

• Provider Enrollment Forms

Medical Records

• Do I Have the Right to See My Medical Records?
• Denial of Access to Patient Information and Appeal Form (PDF, 35KB, 2pg.)

Minimum Data Set (MDS) - New York State Requirements

• Section S:
  • Effective for assessments in the period: 4/1/2011 - Current
    • Form
    • Instructions (Updated 03/29/2011)
  • Effective for assessments in the period: 10/1/2010 - 3/31/2011
    • Form
    • Instructions
• Section Z: Assessment Administration (New York)
  • Instructions Effective 10/01/2010 (Updated 01/31/2011)
• Other documentation:
  • Section S Crosswalk (by assessment dates) October, 2010 'mapped' to April, 2011 (Updated 05/12/2011)
  • NY Appendix A: MDS 3.0 NY-Specific Requirements - Effective 10/01/2010 (Updated 03/29/2011)
  • NY Appendix B: jRAVEN Configuration Instructions for NY - Effective 10/01/2010 (Updated 01/31/2011)
• Dear Administrator Letter:
  • 11-02 - MDS 3.0 Requirements (Release Date - March 29, 2011)
  • 11-03 - MDS 3.0 Errata (Release Date - April 15, 2011 )
• ZIP of above files (in MS-Word/MS-Excel format; Updated 05/12/2011)
• CMS MDS 3.0 resources (scroll to the Download section of each page)
  • Training materials - Includes the form and instructions
  • Technical information - Includes technical specifications and errata

Mortality

• Infant Autopsy Protocol (PDF, 256KB, 2pg.)

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Narcotic Enforcement

• See Controlled Substances

Nursing Home Administrator (NYS)

• Criminal History Record Check Request Form
• Nursing Home Administrator Licensure Application and Continuing Education Reporting Forms

Nursing Home Complaints

• Complaints About Nursing Home Care

Nursing Home Nurse Aide (NYS)

• Nursing Home Nurse Aide Application and Forms

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Official Prescription Program

• See Controlled Substances

Organ and Tissue Donor Registry (NYS)

• New York State Donate Life Registry Enrollment Form (PDF, 46KB, 1pg.)
• New York State Donate Life Registry Specification Form (PDF, 46KB, 1pg.)

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Patient Review Instrument

• Hospital and Community Patient Review Instrument (H/C-PRI) (PDF, 42KB, 4pg.)
  • Hospital and Community Patient Review Instrument Instructions (PDF, 64KB, 19pg.)

Pesticides

• Emergency Pesticide Application Notification Exemption Reporting Form

Professional Licenses

• Forms from the Office of the Professions, NYS Education Department

Professional Medical Conduct and Physician Discipline

• File a Complaint about a Physician or a Physician Assistant
• Denial of Access to Patient Information and Appeal Form (PDF, 35KB, 2pg.)

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Public Water Supply and Protection

• Cross-Connection Control
• Drinking Water State Revolving Fund (DWSRF)
• Operator Certification
• Water System Operation

Publications Catalog, NYS Health Department

• Publications Catalog Order Form

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Rabies

• Rabies Materials Order Form

Radiologic Science

• Application of Radiologic Technologist Licensure

Radon

• Radon Test Kits
• Radon Reporting

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SCREEN/PASRR

• DAL 09-08 - Revised SCREEN Form Implementation (November 12, 2009)
• SCREEN Form DOH-695 (02/2009)
• Revised Page 4 of Instruction Manual for SCREEN Form DOH-695 (02/2009)
• Instruction Manual for SCREEN Form DOH-695 (02/2009)
• Frequently Asked Questions (Revised October 2010)

Swimming Pools

• Swimming Safety
• Engineering Report for Swimming Pool Plans
• Report on Operation of Swimming Pool
• Engineering Report Form for Bathing Beaches
• Daily Report on Beach Operation
• Swimming Pool & Bathing Beach Safety Plan Checklist (PDF, 57KB, 2pg.)
• Written Notification for Supervision of Bathing Facilties at Temporary Residences & Campgrounds (PDF, 15KB, 2pg.)
• Swimming Pool Plan Review Check Sheet (PDF, 15KB, 2pg.)

Statewide Planning and Research Cooperative System (SPARCS)

• Miscellaneous SPARCS Forms

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Temporary Assistance

• Home Energy Assistance Program (HEAP)
• Temporary Assistance, Medical Assistance, Food Stamp Benefits, and Services including Foster Care and Child Care Assistance

Tick Identification Service

• Tick Identification Submittal Form
• Tick Materials Order Form

West Nile Virus

• West Nile Virus Materials Order Form

Wadsworth Center

• Clinical Laboratory Evaluation Program (CLEP)
• Blood and Tissue Resources Program (BTRP)
• Environmental Laboratory Approval Program (ELAP)

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