Doh 4235-2025

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The document is a notification form from the New York State Department of Health's Office of Health Systems Management, used for requesting waivers or equivalencies related to regulatory standards for facilities. It outlines the necessary identifying information, types of waivers available, and requirements for submitting a request, including justifications and supporting documentation. The form also includes sections for departmental use to track the approval process.

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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, phone number, and signing the form. Double-check for completeness before submission.

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