NewYorkStateDepartmentofHealthEvidence‐BasedDossierProcess:
SubmissionofAdditionalEvidence
To submit additional sources of evidence to the New York State Department of Health for consideration during the dossier review process, please use this form. The Department will contact you to acknowledge that your submission was received. A completed Quality Appraisal Checklist must accompany each additional source of evidence submitted. Send a hard copy of each additional source of evidence, Quality Appraisal Checklist and this completed cover sheet to: Department of Health
Office of Health Insurance Programs
99 Washington Avenue
One Commerce Plaza ‐720
Albany, NY 12210
ATTN: Dossier Review Unit
Name of Individual Submitting Additional Evidence Company/Organization Address Phone Email Address Dossier Topic Under Review Additional Sources of Evidence: Please list below the additional sources of evidence you are providing to the Department of Health in alphabetical order by the primary author’s last name. Indicate the type of study provided (e.g., systematic review; randomized control trial; observational study; expert panel/professional guideline; single expert/case report; etc.) and include a brief explanation why this study should be considered by the Department. Reference Type of Study Rationale for Consideration as Additional Source of Evidence