New York State Department of Health Forms

This form is used as a supplement to the Access NY Health Care Application DOH-4220 for individuals who speak Haitian Creole and reside in New York. It provides additional information and instructions in Haitian Creole language.

This form is a supplement to the Access NY Health Care Application for Italian speakers in New York. It helps Italian speakers complete the application process.

This form is used for the Access NY program in New York. It is a supplement form in Spanish (DOH-4495A Suplemento A) for applicants who need assistance in accessing healthcare and other benefits.

This Form is used for accessing the HT Supplement A program under Access NY in New York, specifically for individuals who speak Haitian Creole.

This form is used for accessing benefits through the Access NY program in New York specifically for Italian-speaking individuals.

This form is a supplement to the Access NY Health Care Application for individuals in New York who speak Korean. It is known as the DOH-5178A-KO Supplement A.

This form is used as a supplement to the Access NY Health Care Application form DOH-4220 for Russian speakers in New York. It provides additional information or clarifications in Russian language.

This form is used for providers in New York to request a change in their status.

This form is used for notifying and requesting approval for an unlicensed acting administrator in New York.

This document is a request for exemption from mandatory infection control training in New York based on equivalent training.

This document is for professionals in New York who are seeking an exemption from mandatory infection control training due to the nature of their professional practice.

This form is used for providers in New York to reapply for permission to administer or discontinue infection control training.

This type of document provides a general list of items or information related to New York. It could include anything from attractions, events, services, or important contact numbers in New York.

This document is used for recording information about individuals with gastroenteritis in New York.

This form is used for tracking and documenting cases of Clostridium difficile infection in New York.

This form is used for reporting and monitoring nosocomial infections in health care facilities in New York.

This document is used for tracking cases of influenza, influenza-like illnesses, and upper respiratory illnesses in New York. It helps in monitoring the spread and impact of these illnesses.

This Form is used for documenting and tracking cases of skin infections in New York. It helps in monitoring the spread of infections and implementing necessary preventive measures.

This Form is used for applying for HMO/Phsp certification in New York.

This form is used for regulatory compliance in New York.

This form is used for the management contract statement and certification in the state of New York. It is a document that must be completed and submitted according to state regulations.

This Form is used for applying to become a Preferred Provider Organization (PPO) under Workers' Compensation in New York.

This form is used for members in New York to request specific protected Medicaid health information.

This form is used for providers in New York to certify their contract statement and eligibility.

This form is used for filing a complaint related to healthcare services in New York. It is available in Haitian Creole language.

This document is a complaint form used in New York for submitting grievances.

This form is used for lodging complaints in New York and is available in Arabic language.

This form is used for designating a water operator in responsible charge in the state of New York.

This Form is used for Water System Operators in New York to apply for the renewal of certification.

This form is used for applying for the approval of backflow prevention devices in New York.

This form is used for applying for a Certificate of Approval for bottled or bulk water facilities in New York.

This Form is used for applying for approval of plans for a new public water supply improvement in the state of New York.

This Form is used for applying for a Certificate of Waiver from disinfection requirements in New York.

This Form is used for determining the plan review fee schedule in New York for various projects.

This form is used for certification of lead and copper materials and for applying for a waiver from lead and copper sampling in New York.

This form is used for applying for approval of sanitary facilities for a single lot in an unapproved realty subdivision in New York.

This form is used for obtaining an engineer's certification of the completion of a public water improvement project in New York. It is a requirement to ensure that the project has been completed according to the necessary standards and specifications.

This form is used to apply for a specific waiver for residential on-site wastewater treatment systems in New York.