Criminal History Record Check
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2DOH CHRC 101 (5/14) – Page 1
NYS Department of Health
AUTHORIZED PERSON
DESIGNATION FORM AND
CHRC Unit
NOTARIZED SWORN STATEMENT
Phone: 518-402-5549
Fax: 518-474-7477
PAGE 1
chrc@health.state.ny.us
CRIMINAL HISTORY RECORD CHECK
(CHRC)
For Department use only
Leave blank
PROGRAM
The purpose of this form is to designate the Authorized Person for your Agency that is allowed to
request, on behalf of your Agency, fingerprints and criminal history record checks pursuant to Article
28-E of the Public Health Law and Section 845-b of the Executive Law.
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.
“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 record checks on behalf of the Agency.
“Subject individual” is an “employee” as defined by Public Health Law Section 2899(3).
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. One form must be completed for each Authorized Person.
2. The Authorized Person must have a current Health Commerce System (HCS) account.
3. The Agency Representative must sign and date this form where indicated; the Authorized Person’s notarized
signature is required.
4. This form and DOH CHRC 100 (Agency Request Form) must be forwarded to the DOH CHRC Unit by fax or scan
BEFORE submitting subject individual CHRC requests can begin.
SECTION 1 – AGENCY REPRESENTATIVE APPROVAL
I hereby designate the individual identified in Section 2 to serve as the Authorized Person for the Agency as noted on this form.
Name: ____________________________________________________
Title: ________________________________________
Signature of Agency Representative: ___________________________________________
Date: _______________________
(refer to definition of Agency representative shown above-must have already sent CHRC 100 previously)
SECTION 2 – AUTHORIZED PERSON
Last Name
First Name
M.I.
Title
Work Email Address
Work Phone Number
HCS User ID (must have active account)
Agency Name
Agency PFI number or LHCSA Operating License number
Work Address (Street)
City
State
Zip
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