Doh 4235-2026

The document is a notification form from the New York State Department of Health for requesting waivers or equivalencies related to health facility regulations. It outlines the necessary identifying information, types of waivers available, and requirements for submission, including justifications for the request and supporting documentation. The form emphasizes that incomplete requests will not be processed and details the approval process by various health department officials.

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Click ‘Get Form’ to open the doh 4235 in the editor.
Begin with Section A, where you will input identifying information such as the facility name, address, and certification details. Ensure all fields are filled accurately to avoid delays.
Move to Section B, where you must indicate if you are requesting an equivalency or waiver. Select 'Yes' or 'No' and provide the necessary citations and explanations for your request.
In Section II of Waivers, specify the type of waiver you are applying for by checking the appropriate boxes. Provide a detailed explanation of why the waiver is necessary and how you plan to maintain compliance with health regulations.
Complete the operator/administrator/designee section by printing your name, providing a phone number, and signing the form. Double-check that all required documentation is attached before submission.

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