New York State Department of Health Forms

This form is used for authorizing the release of protected Medicaid member information to a third party in New York.

This form is used for individuals in New York who have been denied access to their own patient information and want to file an appeal.

This form is used for reporting the operation of recreational aquatic spray grounds in New York.

This form is used for submitting a confidential case report in New York.

This Form is used for certifying the Monthly Cash Receipts Assessment Report in New York.

This form is used for adoptees in New York to register their information and request access to their original birth certificate.

This form is used as a supplemental document for the Access NY Health Care Application (DOH-4220) in the state of New York.

This form is used for appointing an agent to control the disposition of remains in the state of New York.

This Form is used for designating or changing a Medicaid authorized representative in New York. It is available in Spanish.

This form is used for designating or changing an authorized representative for Medicaid in New York.

This form is used for designating or changing the authorized representative for Medicaid in New York. It is available in Chinese.

This document is for requesting or making changes to the designation of a Medicaid authorized representative in New York for individuals who speak Haitian Creole.

This Form is used for designating or changing an authorized representative for Medicaid in New York, specifically for Italian-speaking individuals.

This document is used to designate or change a Medicaid authorized representative in New York for Korean speakers.

This form is used for designating or making changes to a Medicaid authorized representative in New York for Russian speakers.

This Form is used for requesting the Influenza Vaccine in the state of New York.

This form is used for reporting communicable diseases related to rabies in New York. It is a required document for tracking and preventing the spread of the disease.

This form is used for the Health-Related Legal Services Program Attestation in New York. It is a document that verifies the eligibility and participation of individuals in the program.

This form is used for registering biological siblings in the Adoption Information Registry in New York.

This form is used for determining medical eligibility for uninsured care programs in New York. It helps individuals without health insurance access necessary medical services.

This form is used for applying to the Uninsured Care Program for HIV in New York. It is written in Spanish.

This form is used for applying for the Uninsured Care Programs in New York. It is specifically designed for French-speaking individuals.

This form is used for applying for the Uninsured Care Programs in New York, but it is specifically translated into Haitian Creole.

This Form is used for applying for New York's Uninsured Care Programs specifically designed for Italian residents who do not have health insurance coverage.

This document is used for practitioners in New York to establish an agreement with patients for Adap Plus services.

This document explains the Medicaid Spenddown/Surplus program in New York. It outlines how individuals can qualify for Medicaid by spending down their excess income or assets.

This form is used for creating a legally binding agreement between a home care provider and a client in New York. It outlines the services to be provided, payment terms, and responsibilities of both parties.

This document is used for the Practitioner Specialty Provider Agreement for the Pre-exposure Prophylaxis Assistance Program (Prep-Ap) in New York. It outlines the agreement between practitioners and the program for providing specialized medical services related to HIV prevention and treatment.

This document is a specialty provider agreement for healthcare providers in New York. It outlines the terms and conditions between the provider and the organization they are contracting with. This agreement helps ensure that both parties are aware of their rights and responsibilities.

This Form is used for authorizing the release of health information and confidential HIV-related information in New York, but in French.

This form is used to authorize the release of health information and confidential HIV-related information in New York for Italian residents.

This document is used for authorizing the release of health information, including alcohol/drug treatment, mental health information, and HIV/AIDS-related information. It is specific to New York and is available in Korean.

This form is used for authorizing the release of health information, including alcohol/drug treatment, mental health information, and confidential HIV/AIDS-related information in New York. The form is available in Haitian Creole.