DAL 16-19 Architectural Waiver Form DOH-5226
October 19, 2016
DAL 16-19 Architectural Waiver Form DOH-5226
Dear Administrator:
The purpose of this letter is to inform you that the Division of Adult Care Facility and Assisted Living Surveillance has developed a new architectural waiver form, that must be submitted along with the Adult Care Facility (ACF) Waiver Request/Equivalency Notification Form (DOH-4235) when seeking a waiver of architectural requirements. The new waiver form is available as an enclosure to this letter and is posted on the Department of Health’s website under ACF forms at the following link: http://www.health.ny.gov/facilities/adult_care/forms.htm.
The Construction/Architectural Waiver Request Form (DOH-5226) must be filled out in its entirety, completed and signed by a licensed architect. Any supporting documentation should also be submitted with the DOH-5226 form. For architectural waivers, the DOH-4235 along with the DOH-5226 should be sent to your Regional Office, with a copy of both forms submitted to:
New York State Department of Health875 Central Avenue
Albany, New York, 12206
Attention: Linda O’Connell
If you have any questions regarding information needed on the form, you should contact your Regional Office. Thank you for your ongoing cooperation with our efforts to improve the licensure and waiver process.
Sincerely,
Valerie A. Deetz, Director
Division of ACF/Assisted Living Surveillance
