New York State Breastfeeding, Chestfeeding, and Lactation Friendly Practice Designation Registration Form

Please complete this registration form if you're interested in becoming designated as a Breastfeeding Friendly Practice.  After submitting this registration form, the primary contact listed on the registration form will receive a confirmation email from 'Survey Builder' with a copy of the responses submitted.  In the following days, the primary contact will also receive a separate email from promotebreastfeeding@health.ny.gov with a Practice Designation ID#.  Practices will need to include this ID# on all communications with DOH about the practice designation process, including pre assessments, post assessments, and policies.

8. Practice type:
9. Approximate percentage of patient population eligible for Medicaid:
11. Has this practice applied for Breastfeeding Friendly Practice Designation before?
12. Is this practice currently working with a Breastfeeding, Chestfeeding, Lactation Friendly New York (BFFNY) grantee to achieve designation?