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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

New York State
Office of Mental Health
Bureau of Inspection and Certification
44 Holland Avenue, Albany, NY 12229
Kenneth R. Gnirke, Director

REQUEST FOR AMENDMENT TO OPERATING CERTIFICATE

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Instructions: Submit one copy of this request to OMH's local field office licensing unit and one copy to the Bureau of Inspection and Certification at the above address. This form is to be used only for the changes noted below. All other changes require a Prior Approval Review (PAR) application per 14 NYCRR 551. PLEASE TYPE or PRINT LEGIBLY

Agency:

Program:

Satellite:

OC #:

OC #:

Requestor Name:

Name (printed)

Signature

Title:

Telephone #:

Date:

Identify type of change requested by checking boxes on the left & indicate current information in the “FROM” section and requested change in the “TO” section.
IDENTIFYING INFORMATION FROM TO
Name:
box Sponsor box Agency box Facility
box Program box Satellite
   
Address: (corrections only-relocations require a PAR)
box Sponsor box Agency box Facility
box Program box Satellite box Apartment/Family Based Treatment Site (additions/deletions do not apply and require a different form)
   
FOR OUTPATIENT PROGRAMS ONLY (any of these may require a PAR application.):
Days/Hours of Operation:
box Program box Satellite
   
Additional or Optional Services:
box addition box deletion for:
box Program box Satellite
   
Population:
box addition box deletion for:
box Program box Satellite
   

REASON FOR REQUEST:
Include in request, as applicable:

  1. For corporate name changes provide Certificate of Amendment to Certificate of Incorporation
  2. For programmatic changes, factors influencing the need for the change.
  3. Effect on staff organization, supervision and scheduling; funding sources; budget
  4. Impact on program recipients; transportation; other service providers