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
• Health Information Technology (Health IT)
• Press Releases & Reports
• Freedom of Information Law
• Webcasts
• Related Sites

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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.)

Americans with Disabilities Act

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

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

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

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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

Employment

• Employment Application

Genealogy

• Genealogy Copies
• Genealogy Application

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Health and Safety Outdoors

• General Forms

Health Care Coverage

• Child Health Plus
• 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

Health Care Reform Act (HCRA)

• HCRA Forms

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.)
• 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

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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 Section S (NYS))

• Section S

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 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, 58KB, 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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Radiologic Science

• Application of Radiologic Technologist Licensure

Radon

• Radon Detector Order Form
• 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

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

Wadsworth Center

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

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