Doh chrc 101 2026

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The document is a form from the New York State Department of Health for designating an Authorized Person who can request criminal history record checks on behalf of an agency. It outlines definitions, instructions for completing the form, and requirements for notarization. The Authorized Person must have a current Health Provider Network account and is responsible for ensuring compliance with legal requirements regarding criminal history checks.

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Click ‘Get Form’ to open the DOH CHRC 101 in the editor.
Begin by filling out Section 1, where the Agency Representative must designate the Authorized Person. Ensure you include their name, title, signature, and date.
In Section 2, provide detailed information about the Authorized Person. This includes their last name, first name, work email address, work phone number, HPN User ID, agency name, title, and agency PFI or operating license number.
Proceed to Section 3 and read through the Authorized Person Sworn Statement. Confirm that all statements are accurate and complete as this section attests to your authority in requesting criminal history checks.
Finally, complete Section 4 by signing as the Authorized Person. Ensure notarization is done as required before submitting the form along with DOH CHRC 100 to the specified address.

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