The PSYCKES Access Contact Form must be completed by organizations interested in access to the New York State Office of Mental Health (OMH) PSYCKES application.

Provider agency organizations will need to develop policies and procedures for implementing PSYCKES. OMH strongly encourages organizations to designate individuals with institutional expertise and leadership responsibilities aligned with this requirement.

****PLEASE READ BEFORE PROCEEDING****

Please have the below information available:

1. Contact information: The name, title, address, phone number, and email address for the following persons (and for CEOs only, fax number):

          Chief Executive Officer or Executive Director
          Chief Operating Officer or Deputy Director
          PSYCKES Point Person 1
          PSYCKES Point Person 2
          Additional PSYCKES Point Persons (if applicable)

2. Signed PSYCKES Confidentiality Agreement: Fill-in and have the CEO/ED of the organization (or another person who is legally authorized to bind the organization to the contractual terms) sign the PSYCKES Confidentiality Agreement found here. Once signed, scan and submit the agreement to PSYCKES-Help@omh.ny.gov

3. To expedite your access request, provide the below information for the provider agency organization (optional). Note: Managed Care Plans and DSRIP PPS Organizations do not need to enter this information.

          Taxpayer Identification Number (TIN)
          Medicaid Provider ID 

If the above information is not readily available, please exit the form by clicking “Exit” at the top right corner of your screen and return to complete the form.

To verify an organization's PSYCKES access status, or for questions about this form, email PSYCKES-Help@omh.ny.gov.

T