DOH-5232 122216 copy-2026

1. Click ‘Get Form’ to open the DOH-5232 122216 copy in the editor.
2. In Section 1, enter your personal information including your first name, middle name, last name, NY State of Health Account ID, and date of birth in the specified format (MM/DD/YYYY).
3. Proceed to Section 2 where you will provide details about your appointed representative. Fill in their first name, middle name, last name, mailing address (street or PO box, city, state), phone number, and organization name if applicable.
4. In Section 3, sign and date the form. This signature authorizes your representative to act on your behalf regarding your appeal. Ensure you also indicate your relationship if someone other than yourself is signing.
5. Once completed, save the document. You can then upload it directly through our platform or choose to fax or mail it as per the submission instructions provided.

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