Follow the steps to successfully complete your form online.

1. Click the ‘Get Form’ button to access the DOH-5232 122216 Copy online and open it for editing.
2. In Section 1, fill in your personal information. Include your first, middle, and last names, along with your NY State of Health Account ID and date of birth in the specified format (MM/DD/YYYY).
3. Proceed to Section 2. Here, provide details about your chosen representative. Include their first, middle, and last names, mailing address, city, state, zip code, phone number, and organization name if applicable.
4. In Section 3, you will sign and date the form. This signature indicates that you authorize the person listed in Section 2 to act on your behalf regarding your appeal. Ensure the date is formatted as MM/DD/YYYY.
5. After completing all sections of the form, review it for accuracy to ensure all information is correct.
6. Save any changes made to the document, then either download, print it, or share it as needed. Ensure you keep a copy for your records.

Complete your DOH-5232 122216 Copy online today to ensure effective representation in your appeal process.