New York State

Information for a Healthy New York

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• Birth, Death, Marriage & Divorce Records
• Health Insurance Programs
• Employment Opportunities
• Forms
• Family & Community Health
• Health Care Professionals & Patient Safety
• Hospitals, Nursing Homes & Other Health Care Facilities
• Diseases & Conditions
• Health & Safety in the Home, Workplace & Outdoors
• Healthy Lifestyles & Prevention
• Laws & Regulations
• Statistics & Data
• Events & Training
• Grants/Funding Opportunities
• Permits, Licenses & Certification
• Press Releases & Reports
• Freedom of Information Law
• Webcasts
• Related Sites

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Forms

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

Americans with Disabilities Act

• Americans with Disabilities Act Complaint Form (PDF, 12KB, 2pg.)

Asbestos

• Application for Asbestos Training Equivalency (DOH-4353) (PDF, 21KB, 2pg)

Assisted Living

• Assisted Living

Birth, Death, Marriage, Divorce

• Birth Certificates
• Death Certificates
• Marriage Certificates
• Divorce Certificates
• Genealogy Copies
• Adoption Information Registry Forms
• Disposition of Remains

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

Communicable Disease

• Communicable Disease Reporting Form

Controlled Substances / Narcotic Enforcement

• Narcotic Enforcement Forms

Dental

• Oral Health Education and Publications Order Form (PDF 16KB 1pg)

Diabetes

• Diabetes Publications Order Form

Disposition of Remains

• Disposition of Remains

Do Not Resuscitate (DNR) Orders

• Nonhospital Order Not to Resuscitate

Early Intervention

• Application for Approval of Individual Evaluators, Service Providers and Service Coordinators
• Application for Approval of Agencies or Incorporated Groups of Individuals as Evaluators, Service Providers and Service Coordinators
• Early Intervention Publications Order Form

Emergency Medical Services (EMS)

• Forms Commonly Used by EMS Providers and Agencies
• Forms Used in EMS Education
• Recertification Forms
• Reciprocity Forms

Health Care Coverage

• Child Health Plus
• Elderly Pharmaceutical Insurance Coverage (EPIC)
• 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

Health Care Proxy

• Health Care Proxy Form

Health Care Reform Act (HCRA)

• HCRA Forms

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

Immunization

• Influenza/Pneumococcal Immunization Data Report (DOH-4193) (PDF, 22KB, 1pg.)
  • Instructions for Influenza/Pneumococcal Immunization Data Report (DOH-4193) (PDF, 75KB, 2pg.)

Infection Control

• Infection Control Reporting/Training Forms

Managed Care

Contact OMC for assistance and information on appropriate use.

• Provider Contract Statement and Certification (DOH-4255) (PDF, 88KB, 5pg.)
• Utilization Review Agent Registration Application and Attestation (DOH 4291A) (PDF, 66KB)
• Utilization Review Agent Registration Application Summary/Checklist (PDF, 77KB, 16pg.)
• Disclosure Information for Character and Competency Review (DOH 793B) (PDF, 108KB, 10pg.)
• Disclosure of Affiliations with Other Health Care Operations(DOH 793C) (PDF, 51KB, 2pg.)
• Regulatory Compliance Statement (DOH 794) (PDF, 61KB, 2pg.)

Medicaid

• Obtaining Medicaid Payment Records

Medicaid Provider (NYS)

• Provider Enrollment Forms

Minimum Data Set (MDS Section S (NYS))

• Section S

Mortality

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

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 Nurse Aide (NYS)

• Nursing Home Nurse Aide Application and Forms

Official Prescription Program

• See Controlled Substances

Organ and Tissue Donor Registry (NYS)

• Organ and Tissue Donor Registry Enrollment Form

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

• Complaint about a Physician or a Physician Assistant

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

Radiologic Science

• Application of Radiologic Technologist Licensure

Radon

• Radon Detector Order Form
• Radon Reporting

Swimming Pools

• Swimming Safety
• Report on Operation of Swimming Pool

Statewide Planning and Research Cooperative System (SPARCS)

• Miscellaneous SPARCS Forms

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