Acting Commissioner Kristin M. Woodlock, RN,
MPA
Governor Andrew M. Cuomo
Office of Mental Health (OMH) Forms
OMH Forms Listed by Form Number
OMH has a number of forms available. The listing below is the forms that can be downloaded and printed from the Internet. There are also some forms available for a fee. These are listed in the Printing & Design Services Catalog or call the Design Center at (518) 473-3574.
Application for Prior Approval Review
- Form OMH 167
(859kb) - Application for Prior Approval Review 14 NYCRR 551 Personalized Recovery Oriented Services (PROS) Program (Part 512) - Prior Approval Review (PAR) Application Status
Continuous Quality Improvement (CQI) Initiative
- CQI Plan Template
(165kb) (HTML | Word Version
) - NYC Instructions for First Year Evaluation
(92kb) (HTML)
- NYC Template for First Year Evaluation
(428kb) (HTML | Word Version)
- Instructions for First Year Evaluation for Central, Hudson River, Long Island, and Western Regions
(1mb) (HTML)
- Template for First Year Evaluation for Central, Hudson River, Long Island, and Western Regions
(68kb) (HTML | Word Version)
- Instructions and Template for Second Year Evaluation
(616kb) (HTML)
Consolidated Fiscal Reporting System (CFRS)
- Calendar Year 2009 (January - December) Schedules & Forms
- Fiscal Year 2009/10 (July - June) Schedules & Forms
Criminal History Background Checks
- Article 28 Participation Form
(21kb)
- Authorized Person Designation Form *
(22kb)
- Authorized Person Notarized Sworn Statement
(33kb)
Employment Forms
Health Insurance Portability and Accountability Act (HIPAA)
- Authorization for Patient Interview – OMH – 445
- Authorization for Patient Photograph – OMH – 446
- Notice of Privacy Practices - Standard
(35kb)
- OMH Sample Agreement – QA – 530
- Standard Authorization Form – OMH – 11
(127kb)
- Status of OMH as Covered Entity
Home and Community Based Services Waiver Program Forms
- Administrative Review
(329kb) (HTML)
- Aftercare Follow-Up Plan
(498kb) (HTML)
- Application for Participation & Freedom of Choice
(46kb) (HTML)
- CANS MH
(1.6mb) (HTML)
- Children Notice to LDSS Regarding Loss of Waiver Eligibility
(498kb)
- Children's Waiver Financial Information Form
(411kb) (HTML)
- Children's Waiver Transmittal Form with Instructions to Complete/Submit
(437kb) (HTML)
- Discharge Plan
(229kb) (HTML)
- HCBS Waiver Qualification Form: ICC Provider
(37kb) (HTML)
- HCBS Waiver Qualification Form: Subcontractor (37kb) (HTML)
- Initial Service Plan Narrative (ISPN)
(626kb)
- Level of Care (LOC)
(92kb) (HTML)
- Medicaid Application Cover Letter
(495kb)
- Plan of Corrective Actions (POCA)
(494kb) (HTML)
- Progress Notes
(55kb)
- Release of Information
(27kb)
- Safety Alert Plan
(643kb) (HTML)
- Safety Plan Contract
(354kb) (HTML)
- Screening Results Letter
(41kb) (HTML)
- Service Plan/Goals and Objectives
(650kb)
- 30 Days Review Narrative
(737kb)
- 90 Days Review Narrative
(739kb)
- Site-Visit Summary Form
(703kb)
- Transmittal Form for New Enrollments
(40kb)
- Universal Referral Screening Form (URF)
(512kb) (HTML)
Licensing
- Request for Amendment to Operating Certificate
(644kb) ( HTML)
- Request for Apartment Addition or Deletion and Waivers
(668kb)
- Request for Approval - Infrared Portable Space Heater
(501kb)
OMH Procurement Lobbying Act Forms For Vendors
- Offerer's Affirmation of Understanding Attachment J1
(13kb)
- OMH Offerer Disclosure of Prior Non Responsibility Determinations Attachment J2
(15kb)
- Notification of Restricted Period Under Procurement Lobbying Act For Sole, Single or Preferred Vendors Attachment J4
(488kb)
Regulations
- Part 501 of Title 14 NYCRR grants the Commissioner the ability to waive regulatory requirements for purposes of testing innovative programs that may increase the efficiency and effectiveness of operations or providing additional flexibility to better meet local service needs while maintaining program quality and integrity.
Instructions | Waiver Request Form
(568kb)
* If you are having accessibility issues with the previous documents, please contact Omer Jirdeh, or call (518) 473-4144.