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12-05 cfri - New York State Office of Mental Health - omh ny 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in the 'Agency Name' and 'Agency Code' at the top of the form. Ensure that these details are accurate as they identify your organization.
- In the 'Agency Identification and Certification Statement' section, check the appropriate box for your type of ownership: Not-for-Profit, Proprietary, or Governmental.
- Provide your agency's address and county name. If there has been a change in address from the previous reporting period, check the corresponding box.
- Complete the contact information for questions regarding this report, including name, title, telephone number, and email address.
- Select the relevant state agency(ies) by checking OMH, OMRDD, OASAS, or SED as applicable.
- Indicate the CFR submission type by checking one of the options: Full CFR, Abbreviated CFR, Article 28 Abbreviated CFR, Mini-Abbreviated CFR, or Estimated Claim.
- Read and acknowledge the certification statement by signing and dating it at the bottom of the form. This confirms that all information provided is true and correct.
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