DOH Revises ACF Forms to Add DOH Form Reference Number
The Department of Health (DOH) has issued a Dear Administrator letter announcing that Adult Care Facility (ACF) forms have been updated to add DOH form numbers. Previously, the forms had only a DSS number assigned. The forms were also revised to include the standard heading of “Adult Care Facility/Assisted Living”. Below is a listing of the forms that have been modified in this manner:
- DOH-5176 (DSS 2900): Adult Care Facility Daily Resident Census Report
- DOH-5177 (DSS 3026): Adult Care Facility Chronological Admission and Discharge
- DOH-5192 (DSS 934): Notice of Change Enriched Housing Apartment Certification for REsidents Receiving SSI
- DOH-5193 (DSS 2854): Adult Care Facility Personal Allowance Ledger
- DOH-5194 (DSS 3027): Adult Care Facility Inventory of Resident Property
- DOH-5195 (DSS 2853): Adult Care Facility Statement Offering Personal Allowance
- DOH-5196 (DSS 2855): Adult Care Facility Personal Allowance Summary
Contact: Diane Darbyshire, ddarbyshire@leadingageny.org, 518-867-8828