Get Department Of Health Application For Doh 3736 Form

Filling out the Department Of Health Application For Doh 3736 Form is an important step for agencies seeking approval as early intervention evaluators, service providers, and service coordinators. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to fill out the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Schedule 1, provide the agency's legal name, address, and tax identification number in the specified fields. Ensure that the name matches the one on organizational documents.
3. List all service delivery sites in Schedule 1 if different from the main site. Provide the name, address, and phone number for each site.
4. Enter the name and title of the contact person responsible for the application in Schedule 1.
5. In Schedule 2, fill out the operator's name, title, and business address. Also, describe any legal actions the operator has faced, avoiding minor traffic violations.
6. Indicate the ownership type in Schedule 2 by selecting only one option. Attach any necessary organizational documents.
7. In Schedule 3, state whether the agency is approved by any state early intervention service agencies and provide relevant details.
8. Outline the proposed services in Schedule 4, indicating the specific services the agency seeks approval for, including evaluation services and service coordination.
9. List the languages spoken by the staff in the agency in Schedule 4.
10. Specify the service catchment area and any special populations served in Schedule 4.
11. In Schedule 5, indicate the availability of qualified personnel in full-time equivalents, providing necessary details for each qualified person.
12. In Schedule 6, affirm compliance with all regulations by providing the authorizing signature, ensuring all signatures are original and the application is notarized.
13. Once the form is completed, save changes, and prepare to download, print, or share the form as needed.

Complete your application online today for timely processing of your request.