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Get Ny Doh-3736 2005-2026
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How to fill out the NY DOH-3736 online
The NY DOH-3736 is a crucial application form for agencies seeking approval as evaluators, service providers, and service coordinators in New York's early intervention program. Completing this form accurately is essential for ensuring proper approval and compliance with state regulations.
Follow the steps to fill out the NY DOH-3736 accurately.
- Click the ‘Get Form’ button to obtain the application and open it in the editing interface.
- Begin with Schedule 1: General Agency Information. Fill in the agency name, tax identification number, and the full agency address including city, county, and zip code. Provide the contact number and fax number if applicable.
- In Schedule 1, list the name and address of any additional service delivery sites, if they differ from the main agency location.
- Continue to Schedule 2: Operator Information. Provide the name and address of the chief executive officer or executive director, and detail any legal actions against them, including convictions or pending charges.
- In Schedule 3: Agency Affiliation, indicate whether your agency is currently approved by any relevant state early intervention service agencies and provide additional details if necessary.
- For Schedule 4: Project Outline, select the evaluation and service coordination services your agency is seeking approval for, and specify the languages spoken by staff in providing these services.
- Complete Schedule 5: Qualified Personnel. List the qualified personnel available, detailing their employment status and any additional personnel needed.
- In Schedule 6: Assurances, ensure that all compliance statements are acknowledged. Complete the certification section by typing your name, title, and signing the document.
- Once all sections are filled out, review your application for accuracy and completeness. Ensure all necessary supporting documentation is attached.
- Finally, save your changes, and choose to download, print, or share the completed form as required.
Begin filling out the NY DOH-3736 online today to ensure your agency’s approval for early intervention services.
In New York City, you can reach the early intervention program at 311 for assistance. They can guide you through the process and provide information about evaluations and services available. Always refer to the NY DOH-3736 for the most up-to-date contact information and resources.
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