Ny exclusion 2026

1. Click ‘Get Form’ to open the NY Exclusion form in the editor.
2. Begin with Part 1, where you will enter the Authorized Person's details. Fill in the First Name, Last Name, Email Address, M.I., Business Phone, Full Provider Name (avoid abbreviations), Business Address, State, City, and Zip Code.
3. In Part 1, ensure that the Authorized Person signs and dates the form at the designated area to confirm their understanding of responsibilities related to SEL checks.
4. Proceed to Part 2 for Provider Approval. The Director of the Provider Agency must complete this section by entering their Name, Title, Date, and signing below to approve the designation of the Authorized Person.
5. Finally, fill out Part 3 with relevant agency information such as Agency Codes and IDs for oversight agencies as applicable.
6. Once all parts are completed and signed, return the form by scanning and emailing or faxing it to the Justice Center’s CBC Unit using the provided contact information.

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