DAL 15-17: Revised ACF DOH-4235 Waiver Request/Equivalency Notification Form

November 25, 2015

DAL 15-17: Revised ACF DOH-4235 Waiver Request/Equivalency Notification Form

Dear Administrator:

The purpose of this letter is to inform you that the Adult Care Facility Waiver Request/Equivalency Notification Form (DOH-4235) was revised to eliminate content that is no longer applicable, to standardize information contained in the form and to improve the overall appearance. The form is used whenever an operator elects to adopt an approved equivalency or request a waiver that supports an alternative method of complying with a specific regulation(s). This form should not include any resident specific information.

The Adult Care Facility Waiver Request/Equivalency Notification Form (DOH-4235) can be completed and either emailed or mailed to your regional office. When submitting your request either electronically or through mail, please contact your regional office to verify the correct e-mail or mailing address for submission.

The form can be accessed at: http://health.ny.gov/facilities/adult_care/forms.htm.

The Division of ACF/Assisted Living Surveillance will continue to review and update existing forms and notify you of changes. If you have questions regarding the revised forms, please contact the Division of ACF/Assisted Living Surveillance at (518) 408-1133 for further clarification.

Sincerely,

Valerie A. Deetz, Director
Division of ACF/Assisted Living Surveillance

Attachment

cc: B. Barrington
P. Hasan
J. VanDyke
N. Nickasn