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Office of Mental Health

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Prior Approval Review
Sample Letter of Intent – New Provider

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Letter of Intent

Local Government Unit
Mental Health Field Office
Agency name
Agency address

For projects proposed by an agency that currently does not provide mental health services authorized or licensed by Office of Mental Health OMH.

If licensed by any other NYS agency to provide mental hygiene services, please identify type of service and any licensure information. For example, operate a day treatment program licensed by NYS Office of Mental Retardation.

Proposed Action: Identify type of project

Narrative: Please provide a brief description of proposed project, identifying the county/borough involved and include anticipated effective date.

Circle type of application to be submitted: EZ Prior Approval Review (PAR) / Comprehensive PAR

Chief Executive Officer (CEO)/Executive Director:

Contact Person: name & title

Telephone #:

Email address:

Comments or questions about the information on this page can be directed to the Bureau of Inspection and Certification.