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Forms and Templates

  • Information exchange is a critical component of care coordination provided by the Health Home program. By completing the consent form, a member is agreeing to allow his/her Personal Health Information (PHI) to be shared among the consented Health Home partners and, for the Designated Health Home to access information from the Regional Health Information Organization (RHIO) and The Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES). With a signed consent, all providers and others involved in the member’s care has access to the same information to better serve the member.
  • Health Home Patient Information Sharing Consent Forms
  • Policy for Sharing Protected Health Information between HH and MCO (PDF, 52KB)

Health Home Patient Information Sharing - Withdrawal of Consent

If a member chooses to disenroll from the Health Home program s/he must sign a Health Home Patient Information Sharing Withdrawal of Consent Form (DOH-5058). Signing this form indicates not only the member’s intent to disenroll from the program, but also withdraw his/her consent to share health information effective on the date the form was signed. All Health Home partners and others approved by the member on page 3 of the Patient Information Sharing Consent (DOH-5055) must be notified if a member withdraws their consent, and the effective date of withdrawal. If attempts to complete and sign the DOH-5058 are unsuccessful, the care manager must document the member’s request to disenroll from the Health Home program and refusal to complete the DOH-5058.

Health Home Opt-Out

The Health Home program is voluntary. For members who choose to stay actively 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.

Instructions for Completing the Forms (DOH-5055, DOH-5058, DOH-5059)