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Click ‘Get Form’ to open the nys doh 3486i in the editor.
Begin with Part I by entering the identifying information. Fill in the facility name, address, city, state, zip code, and telephone number. Ensure all details are accurate.
Move to Part II for Ownership Information. List names, addresses, and social security numbers of individual owners or partners who possess 5% or more of voting shares. If necessary, attach a separate sheet.
Indicate the ownership type by selecting from options such as Partnership, Government, Individual, etc. If applicable, provide additional owner names and addresses.
In Part III - Declaration, answer questions regarding any administrative violations or criminal convictions related to ownership. Check 'Yes' or 'No' as appropriate.
Complete Part IV by typing or printing the name of the authorized representative and providing their title, signature, date, contact phone number, and email address.

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What is the purpose of the Healthy New York program?

Healthy NY is a program designed to make reduced-cost, comprehensive health insurance available to small employers that do not provide health insurance to their employees.

What does the local health department do?

Local health departments investigate, plan for, respond to, and educate the community and key partners about water-, food-, and insect-borne diseases. Local health departments are an essential part of the process to ensure that food is safe to eat at home, at community events, in restaurants, and in schools.

What is the purpose of the New York State Department of Health?

The Department of Health is responsible for safeguarding the health of New York States residents. The department has direct authority over all health care institutions in the State covered by the Public Health Law, including hospitals, nursing homes, diagnostic and treatment centers, and many home-care providers.

What does the New York State Department of Health do?

The New York State Department of Health (State DOH) protects, improves, and promotes the health, productivity, public safety, and wellbeing of all New Yorkers.

What does the Department of health do in the US?

The mission of the U.S. Department of Health and Human Services (HHS) is to enhance the health and well-being of all Americans, by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services.