Reporting Forms and Instructions
- Schedule of Cash Assessment Payment and Filing Due Dates (PDF, 63KB, 2pg.)
- Instructions for Completing Report Forms (PDF, 22KB, 2 pg.)
- Certification Form (PDF, 19KB, 1 pg.)
- April 1, 2005 - March 31, 2011 Reporting Form (PDF, 97KB, 2 pg.)
- April 1, 2003 - March 31, 2005 Reporting Form (PDF, 50KB, 2 pg.)
- April 1, 2002 - March 31, 2003 Reporting Form (PDF, 49KB, 2 pg.)
New York State designated providers are required to pay an assessment on cash operating receipts on a monthly basis under the Health Facility Cash Receipts Assessment Program pursuant to Chapter 1 of the Laws of 2002 as amended by various subsequent period Chapter Laws.
Effective April 1, 2009, an electronic report must be submitted each month by designated providers, even if there were no assessable cash receipts for the reporting month.
- File Electronically - New York State Office of Pool Administration
To request an alternate format, please call the Bureau of Financial Management and Information Support at (518) 474-1673.