Forms and Templates
- OASAS Letter of Support for Consent (PDF, 28KB, 1pg.)
- Guidance from NYS to Health Homes on Protecting Personal Health Information (PHI) (PDF, 367KB, 1pg.)
- Health Home Patient Information Sharing Consent
- Health Home Patient Information Sharing Withdrawal of Consent
- Health Home Opt-Out
- Health Home Member Letter Templates for Outreach
Health Home Patient Information Sharing Consent
Health Home Program members must provide informed consent in order for their health information to be shared between and among providers who serve them in the Health Home Program. To help ensure that this consent is informed, it is the expectation of New York State that case managers will assist members in Health Home Programs to complete the Health Home Patient Information Sharing Consent Form (DOH-5055) to assure they understand it and have the opportunity to ask questions and have those questions answered. By completing and signing this consent form, a member is agreeing to allow his/her health information to be shared among the Health Home partners, which can include a Regional Health Information Organization (RHIO).
- Policy for sharing Protected Health Information of Enrollees between the MCO and the Health Home Prior to Consent
Instructions for Completing the Form
- List the name of the Health Home or Regional Health Information Organization (RHIO) as appropriate in each blank.
- List the core Health Home partners by corporate/agency name. Core Health Home partners are defined as the main institutional medical health and behavioral health providers and the care management agencies that are likely to serve the majority of 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 patient 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.
- Health Home Patient Information Sharing Consent Forms - This consent form will be available in seven additional languages soon.
- Health Home Consent FAQs for Providers (PDF, 41KB, 7pg.)
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 Patient Information Sharing Withdrawal of Consent Forms - This withdrawal form will be available in seven additional languages soon.
- Health Home Opt-Out and Withdrawal of Consent Forms FAQs (PDF, 89KB, 2pg.)
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.
- Health Home Opt-Out Forms
- Health Home Opt-Out and Withdrawal of Consent Forms FAQs (PDF, 20KB, 2pg.)