DOH Revises ACF Mental Health Evaluation

The Department of Health (DOH) has revised the Adult Care Facility Mental Health Evaluation Form (DOH-5075) to address inconsistencies in completion of the form. Revisions include changes to the directions regarding the completion of the form, a rewording of questions, regulatory references, and a statement reading “No section of this document may be omitted or crossed out. Additional supporting documentation may be attached to this form on the professional’s letterhead to clarify answers.” In addition to the revised form, DOH has issued a Dear Administrator Letter (DAL) and DAL companion.

Questions regarding the new form can be directed to DOH at acfinfo@health.ny.gov.

Contact: Diane Darbyshire, ddarbyshire@leadingageny.org, 518-867-8828