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Requests for applications/forms in an alternate format can be made by sending an e–mail note to dohweb@health.ny.gov.
Adoption
AIDS Institute
- Uninsured Care Programs
- Assignment of Benefits (PDF)
- Addendum to Home Care (PDF)
- Home Health Certification and Plan of Treatment (PDF)
- Nursing Assessment for Home Care (PDF)
- Home Care DME Prior Aproval Request AI–3615 (PDF)
Americans with Disabilities Act
- Americans with Disabilities Act Complaint Form (PDF)
Asbestos
- Application for Asbestos Training Equivalency (DOH–4353) (PDF)
- Application for Approval or Revision of an Asbestos Safety Training Program (PDF)
Assisted Living
Authorized Representative Designation/Change Request
Birth, Death, Marriage, Divorce
Cardiac Surgery and PCI (Angioplasty)
Cash Receipts Assessment Program
Certificate of Need
Child and Adult Care Food Program
Children´s Camps
Communicable Disease
- Mosquito & Tick Materials Order Form (PDF)
- Prevent Herpes Transmission During Ritual Circumcision
- Ordering Brochures (PDF)
Controlled Substances / Narcotic Enforcement
Dental
Disposition of Remains
Do Not Resuscitate (DNR) Orders
- Nonhospital Order Not to Resuscitate (PDF)
Early Intervention
- Early Intervention Publications Order Form (PDF)
Emergency Medical Services (EMS)
Employment
Genealogy
Health and Safety Outdoors
Health Care Coverage
- Health Insurance Application (PDF) – Some applicants are required to apply for Medicare as a condition of eligibility for Medicaid. Please read OHIP–0112 below for more information on who is required to apply for Medicare and how to apply
- Health Insurance and Nutrition Application for Children, Adults, and Families (Medicaid, Child Health Plus, Family Health Plus and Family Planning Benefit Program) (PDF)
- Women, Infants and Children (WIC) Nutritional Program
- Forms for Health Care Providers
- Day Care Centers/Homes
- Certificate of Authority Form (PDF)
Health Care Proxy
Health Care Reform Act (HCRA)
Art Paper 3 0 56 Mm
Health Facilities Cash Assessment Program (HFCAP)
- User ID Application for Electronic Filing
Health Homes
- Health Home Statement and Certification (PDF
- Guidelines for MCOs (PDF)
Helen Hayes Hospital
- Employment Application Form (PDF)
- Volunteer Corps Application Form (PDF)
- TLC Learning Center Application/Wait List Form (PDF)
HIV/AIDS
- Opioid Overdose Prevention Program Registration (PDF)
Home Care Services Agencies
Hospital and Primary Care Services
Art Paper 3 0 56 Inch
Immunization
- Influenza Vaccine (DOH–4482) (PDF)
Infection Control
Lead Poisoning Prevention Education Materials
- Lead Poisoning Prevention Education Materials (PDF)
Managed Care
Medicaid
Medicaid Provider (NYS)
Medical Records
- Denial of Access to Patient Information and Appeal Form (PDF)
Minimum Data Set (MDS) – New York State Requirements
- MDS Audit Clarification Memorandum
- Section S
- Effective for assessments beginning 10/01/2019
- Form (PDF)
- Instructions (PDF)
- Effective for assessments in the period: 10/1/2017 – 9/30/18
- Form (PDF)
- Instructions (PDF)
- Effective for assessments in the period: 4/1/2011 – 9/30/17
- Form (PDF)
- Instructions (Updated 03/29/2011) (PDF)
- Effective for assessments beginning 10/01/2019
- Section Z: Assessment Administration (New York
- Instructions Effective 10/01/2010 (Updated 01/31/2011) (PDF)
- Other documentation
- Section S Crosswalk (by assessment dates) October, 2010 ´mapped´ to April, 2011 (Updated 05/12/2011) (PDF)
- NY Appendix A: MDS 3.0 NY–Specific Requirements – Effective 10/01/2010 (Updated 03/29/2011) (PDF)
- NY Appendix B: jRAVEN Configuration Instructions for NY – Effective 10/01/2010 (Updated 01/31/2011) (PDF)
- Dear Administrator Letter
- 11-02 - MDS 3.0 Requirements (Release Date – March 29, 2011) (PDF)
- 11–03 – MDS 3.0 Errata (Release Date – April 15, 2011) (PDF)
- ZIP of above files (in MS–Word/MS–Excel format; Updated 05/12/2011) (ZIP)
- 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)
Narcotic Enforcement
Nursing Home Administrator (NYS)
Nursing Home Complaints
Nursing Home Nurse Aide (NYS)
Official Prescription Program
Organ and Tissue Donor Registry (NYS)
- New York State Donate Life Registry Enrollment Form (PDF)
- New York State Donate Life Registry Specification Form (PDF)
Patient Review Instrument
- Hospital and Community Patient Review Instrument (H/C–PRI) (PDF)
- Hospital and Community Patient Review Instrument Instructions (PDF)
Pesticides
Professional Licenses
Professional Medical Conduct and Physician Discipline
Public Water Supply and Protection
Publications Catalog, NYS Health Department
Rabies
- Rabies Materials Order Form (PDF)
Radiologic Science
Radon
SCREEN/PASRR
- PASRR Process Changes (Effective December 1, 2017)
- DAL 09–08 – Revised SCREEN Form Implementation (November 12, 2009)
- SCREEN Form DOH–695 (02/2009) (PDF)
- Instruction Manual for SCREEN Form DOH–695 (02/2009) (PDF)
- SCREEN/PASRR Frequently Asked Questions (FAQ) (Revised June 2013)
Statewide Planning and Research Cooperative System (SPARCS)
Swimming Pools
- Swimming Pool & Bathing Beach Safety Plan Checklist (PDF)
- Written Notification for Supervision of Bathing Facilties at Temporary Residences & Campgrounds (PDF)
- Swimming Pool Plan Review Check Sheet (PDF)
Temporary Assistance
Tick Identification Service
Public Water Supply and Protection
Publications Catalog, NYS Health Department
Rabies
- Rabies Materials Order Form (PDF)
Radiologic Science
Radon
SCREEN/PASRR
- PASRR Process Changes (Effective December 1, 2017)
- DAL 09–08 – Revised SCREEN Form Implementation (November 12, 2009)
- SCREEN Form DOH–695 (02/2009) (PDF)
- Instruction Manual for SCREEN Form DOH–695 (02/2009) (PDF)
- SCREEN/PASRR Frequently Asked Questions (FAQ) (Revised June 2013)
Statewide Planning and Research Cooperative System (SPARCS)
Swimming Pools
- Swimming Pool & Bathing Beach Safety Plan Checklist (PDF)
- Written Notification for Supervision of Bathing Facilties at Temporary Residences & Campgrounds (PDF)
- Swimming Pool Plan Review Check Sheet (PDF)
Temporary Assistance
Tick Identification Service
- Tick Materials Order Form (PDF)
West Nile Virus
- West Nile Virus Materials Order Form (PDF)