Forms
Requests for applications/forms in an alternate format can be made by sending an e-mail note to dohweb@health.ny.gov.
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)
- 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
- English, Spanish, Chinese, Haitian-Creole, Italian, Korean, Russian
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
Cardiac Surgery and PCI (Angioplasty)
Cash Receipts Assessment Program
- Reporting Forms and Instructions
- User ID Application for Electronic Filing
- Certification Form
Certificate of Need
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
- Mosquito & Tick Materials Order Form (PDF)
- Prevent Herpes Transmission During Ritual Circumcision
Controlled Substances / Narcotic Enforcement
Dental
Disposition of Remains
Do Not Resuscitate (DNR) Orders
- Nonhospital Order Not to Resuscitate (PDF)
- Nonhospital DNR and Do Not Intubate (DNI) Order
Early Intervention
- Early Intervention Publications Order Form (PDF)
Emergency Medical Services (EMS)
Employment
Genealogy
- Genealogy Copies
- Genealogy Application
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
- Forms for Health Care Providers
- Information for Health Care Providers
- Certificate of Authority Form (PDF)
Health Care Proxy
Health Care Reform Act (HCRA)
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)
Health Homes
- Health Home Statement and Certification (PDF
- Guidelines for MCOs (PDF)
Helen Hayes Hospital
- Employment Application Form (PDF)
- Volunteer Corps Application Form (PDF)
- Founders Fund Enrollment Form
- MacArthur Park Order Form
- TLC Learning Center Application/Wait List Form (PDF)
HIV/AIDS
- HIV/AIDS Forms
- Opioid Overdose Prevention Program Registration (PDF)
Home Care Services Agencies
Hospital and Primary Care Services
Immunization
- Influenza Vaccine (DOH-4482) (PDF)
Infection Control
- Infection Control Training Forms
- Infection Control Reporting Forms
Lead Poisoning Prevention Education Materials
- Lead Poisoning Prevention Education Materials (PDF)
Managed Care
Medicaid
- Obtaining Medicaid Payment Records
- Application
Medicaid Provider (NYS)
Medical Records
- Do I Have the Right to See My Medical Records?
- Denial of Access to Patient Information and Appeal Form (PDF)
Minimum Data Set (MDS) - New York State Requirements
- MDS Audit Clarification Memorandum
- Effective for assessments beginning 10/1/2023
- Form (PDF)
- Instructions (PDF)
- Form (PDF)
- Instructions (PDF)
- Form (PDF)
- Instructions (PDF)
- Form (PDF)
- Instructions (Updated 03/29/2011) (PDF)
- Instructions Effective 10/01/2010 (Updated 01/31/2011) (PDF)
- 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)
- 11-02 - MDS 3.0 Requirements (Release Date - March 29, 2011) (PDF)
- 11-03 - MDS 3.0 Errata (Release Date - April 15, 2011) (PDF)
- Training materials - Includes the form and instructions
- Technical information - Includes technical specifications and errata
Mortality
Narcotic Enforcement
Nursing Home Administrator (NYS)
- Criminal History Record Check Request Form
- Nursing Home Administrator Licensure Application and Continuing Education Reporting Forms
Nursing Home Complaints
Nursing Home Nurse Aide (NYS)
Official Prescription Program
Organ and Tissue Donor Registry (NYS)
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
- File a Complaint about a Physician or a Physician Assistant
- Denial of Access to Patient Information and Appeal Form
Public Water Supply and Protection
- Cross-Connection Control
- Drinking Water State Revolving Fund (DWSRF)
- Operator Certification
- Water System Operation
Publications Catalog, NYS Health Department
Rabies
- Rabies Materials Order Form (PDF)
Radiologic Science
Radon
- Radon Test Kits
- Radon Reporting
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)
- Revised Page 4 of Instruction Manual for SCREEN Form DOH-695 (02/2009)
- 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 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)
- Written Notification for Supervision of Bathing Facilties at Temporary Residences & Campgrounds (PDF)
- Swimming Pool Plan Review Check Sheet (PDF)
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 Materials Order Form (PDF)
West Nile Virus
- West Nile Virus Materials Order Form (PDF)
Wadsworth Center
- Clinical Laboratory Evaluation Program (CLEP)
- Blood and Tissue Resources Program (BTRP)
- Environmental Laboratory Approval Program (ELAP)
Revised: September 2023
Department of Health
General Information
- James V. McDonald, M.D., M.P.H., Commissioner
- About the Department of Health
- Meetings & Webcasts
- Employment Opportunities
- Wadsworth Center
- AIDS Institute
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- Councils and Boards
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- Laws & Regulations
- Press Releases, Reports & Publications
- Freedom of Information Law (FOIL)
- Forms
Current Issues/Info
- Abortion in NYS: Know Your Rights
- Addressing the Opioid Epidemic
- Cannabis
- Climate Change and Health
- Cooling Centers
- COVID
- Donate Life - Enroll Today!
- Drinking Water Protection Program
- Ending the Epidemic
- Exposure to Smoke from Fires
- Flu (Influenza)
- Long COVID
- Maternal Mortality
- Master Plan for Aging
- Measles
- Medicaid in New York State
- New York State Physician Profile
- Outdoor Air and Health
- Polio
- Reproductive Health
- RSV
- Vaping and E-Cigarettes
- Wastewater Surveillance
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