Doh Chrc 106 - Revocation Of Authorized Person Designation Form - Nys Department Of Health
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1DOH CHRC 106 (05/14)
NYS Department of Health
REVOCATION OF AUTHORIZED PERSON
CHRC Program
DESIGNATION FORM
Phone: 518-402-5549
Fax: 518-474-7477
chrc@health.state.ny.us
CRIMINAL HISTORY RECORD CHECK
For Department use only
(CHRC)
Leave blank
PROGRAM
The purpose of this form is to revoke the Agency’s Authorized Person Designation status.
TERM DEFINITIONS:
“Agency” means residential health care facility, certified home health agency, adult care facility, licensed home care services agency
or long term home health care programs that are authorized by law to request a check of criminal history record information
pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.
“Agency representative” shall mean a sole proprietor for a sole proprietorship, any authorized partner of a partnership, any
authorized director or officer of a corporation, any authorized member or manager of a limited liability corporation (LLC) or the
policy making body of a government entity for a publicly operated agency.
“Authorized Person” is the individual that is allowed to request criminal history records checks on behalf of the Agency.
Type or print all information – USE CAPITAL LETTERS.
Inaccurate, incomplete or illegible information will delay processing.
INSTRUCTIONS:
1.
Please complete all fields on this form. Since the Authorized Person had a current Health Commerce System (HCS)
account, have your HPN Coordinator additionally remove this individual from your provider’s affiliation.
2. Only one (1) Authorized Person may be revoked on this form.
3. Agency Representative must sign and date Section 2 and previously have submitted a CHRC 100 form to designate themselves to
that role.
4. Please forward the form(s) to the DOH CHRC Unit by fax or scan.
SECTION 1 - AUTHORIZED PERSON IDENTIFICATION
Agency Name
PFI/Operating License No:
Name of Authorized Person
HCS Account ID (if known)
SECTION 2 - AGENCY REPRESENTATIVE
AGENCY REPRESENTATIVE MUST APPROVE EACH REVOCATION OF AUTHORIZED PERSON BY SIGNING BELOW
I hereby revoke the status of the individual identified above to serve as the Authorized Person for the Agency as identified on this
form and have request this individual be removed from the CHRC Authorized Person role on the Health Commerce System.
Name: ____________________________________________________
Title: __________________________________
(Please print)
Signature: _________________________________________________
Date: __________________________________
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