Forms and Templates

Instructions for Completing the Form

  • List the name of the Health Home or Regional Health Information Organization (RHIO) as appropriate in each blank.
  • Health Homes and care management agencies must tailor the consent to the member.
    Options may include:
    • write in only the providers and others agreed upon by the member;
    • list all HH downstream providers and use clearly defined check marks for the member to designate providers they agree to;
    • list all downstream providers and have member cross out and initial those they do not want.
  • List the Health Home partners by corporate/agency name. Health Home partners are defined as institutional medical health and behavioral health providers and the care management agencies that are likely to serve the Health Home members. Also, include Managed Care Plans contracted with the Health Home.
  • Do not include in the initial consent: Individual ordering/servicing practitioners, housing providers, social service support agencies, and criminal justice entities.
  • Additional partners, such as housing, individual servicing or providing practitioners and social support agencies, etc. can be added as needed with an additional page 3 as necessary and must include the patient's initials and the date the member agreed to share information with the new participating partners.
  • Once a consent has been executed, if a Health Home adds partners to its network (such as medical providers or social support entities) that were previously not identified on the consent form, an additional page to the Patient Consent Form is needed to identify these partners.
  • NOTE: Health Homes developing a new corporation should consider how the consent form is filled out with respect to the new corporation's structure, in order to avoid the need to secure a new patient consent form once the new corporation is established. For example, Health Homes may want members to enroll in the Health Home under both their current name and the new name that the Health Home expects to operate under in the near future.
  • Policy for Sharing Protected Health Information between HH and MCO (PDF, 52KB)

Health Home Patient Information Sharing - Withdrawal of Consent

Because information exchange is a critical component of care coordination through a Health Home, if a member withdraws his/her consent to share health information, s/he must also sign a Health Home Patient Information Sharing Withdrawal of Consent Form (DOH-5058) to discontinue sharing information with the Health Home. All participating Health Home partners must be notified if a member withdraws their consent.

Health Home Opt-Out

The Health Home program is voluntary. For members who decide not to stay enrolled in the Health Home program, the Health Home Opt-out Form (DOH-5059) must be completed and signed either by the member or the care manager. These individuals must be disenrolled once the form is completed.