APPLICATION FOR CERTIFICATION

  • Instructions is also available in Portable Document Format (PDF)

NEW YORK STATE DEPARTMENT OF HEALTH MEDICAL RESPITE PROGRAM APPLICATION FOR CERTIFICATION

Instructions

OVERVIEW OF CERTIFICATION PROCESS

The certification process includes two components. To satisfy Component One, you must fill out and submit this certification packet and all required supporting documentation. If New York State Department of Health (DOH) approves the materials you submit for Component One, your program will be invited to schedule Component Two. Component Two consists of an on-site inspection performed by DOH or its contractor.

COMPONENT ONE

  • All forms in the certification packet are fillable PDFs. You may type responses directly into the forms or print out the forms and handwrite responses in blue or black ink. The packet includes:
    • Component One Checklist
    • Application for Certification of Medical Respite Program
    • Medical Respite Program Physical Plant and Safety Plan
  • You may submit the completed certification packet and supporting documentation either by email or standard mail.
  • If submitting by email:
    • Gather electronic versions of all required supporting documentation. Please make sure any scans are easily legible. All files should be saved as PDFs. If possible, please combine all files into a single PDF. If you must submit each document as a separate file, please use descriptive file names (e.g., Program Name_Certificate of Incorporation).
    • Attach the completed application packet and all supporting documentation to an email and send to MRProgram@health.ny.gov.
  • If submitting by standard mail:
    • Make clear photocopies of all supporting documentation. Please label any documents that are not readily identifiable.
    • Send the completed application packet and supporting documentation to:
      New York State Department of Health
      Office of Health Insurance Programs
      Bureau of Social Care and Community Supports
      Attn: Claire Vancik
      One Commerce Plaza Rm. 712
      Albany, NY 12210

WHAT HAPPENS NEXT?

  • DOH will review Component One and notify the program operator of any elements that are incomplete.
    • The program operator must supply the missing element(s) within 90 days of receiving notification from DOH, or DOH may deny the program's application.
  • If DOH finds that the program meets preliminary certification criteria, DOH will notify the program in writing and provide information about Component Two, the on-site inspection.
    • The program operator must schedule the on-site inspection within 90 days of receiving notification from DOH, or DOH may deny the program's application.
  • If you have questions at any stage of the application process, please email MRProgram@health.ny.gov.

Updated August 2024