Get Form Doh-3735(3/05) Application For Approval Of Individual ... - Lighthouse

Filling out the Form DOH-3735(3/05) Application For Approval Of Individual can be a straightforward process if you follow the right steps. This guide provides clear and detailed instructions to help you complete the form efficiently and effectively.

Follow the steps to successfully complete the application

1. Press the ‘Get Form’ button to access the application form and open it in your preferred editor.
2. In Schedule 1, provide your general information, including your name, social security number, and address. Specify if you will deliver services at additional sites as applicable.
3. Complete the Personal Qualifying Information section by entering your profession, license or certification number, the issuing body, and relevant dates. If applicable, describe any past license suspensions or revocations.
4. In the Inservice/Continuing Education section, list any relevant programs attended in the last three years focused on early intervention.
5. Detail your employment history over the past five years, especially experiences related to infants and toddlers at risk of developmental delay. You may attach your current resume if it includes this information.
6. In the Record of Legal Actions section, indicate if you have been convicted of any violations. If ‘Yes’, provide full details as instructed.
7. Move to Schedule 2 and indicate what types of services you are seeking approval to provide. Also, note if you can provide services in languages other than English.
8. In Schedule 3, check all counties where you plan to deliver early intervention services.
9. In Schedule 4, indicate your availability in full-time equivalents for different disciplines that you qualify under.
10. Review the Assurances in Schedule 5, confirming your understanding and agreement to the compliance regulations.
11. Complete the Certification section by signing and dating the application. Ensure accuracy and completeness.
12. Finish by notarizing your Individual Acknowledgment and assembling all necessary documents like the Statement of Reassignment and Provider Agreement.
13. Once completed, save your changes, and you can choose to download, print, or share the form as needed.

Complete your application online to ensure a smooth approval process.