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

NOTE: DOH numbered forms such as the DOH–5055, DOH–5058, and DOH–5059 may not be altered in any way (e.g., use of agency logo, changing original content, attaching other types of forms or documents, altering DOH form numbers or date, adding bar codes, etc. are prohibited).

Section 1: General Instructions for Completing Member Consent Forms (DOH–5055, DOH–5058, DOH–5059)

When completing any form with an individual/member, the care manager should:

  1. Give consideration to the member´s level of understanding and comfort. Legal representation (e.g., guardian) must be involved as appropriate;
  2. Use the form in the language most suitable for the member. If the form is not available in the individual´s chosen language, assure the presence of an interpreter;
  3. Complete all sections of the form as indicated, using full name of Health Home, other entities, phone numbers, etc.;
  4. Review the completed form in full with member and assure understanding prior to signing;
  5. Provide a copy of the completed and signed form to the member; and,
  6. Maintain the original signed form in the member´s record.

Section 2: Health Home Patient Information Sharing Consent form (DOH–5055)

By completing the DOH–5055 consent form, a member is agreeing to allow his/her health information to be shared among the consented Health Home partners and for the Designated Health Home to access the RHIO and PSYCKES for information For new Health Home members, the consent does not have to be signed immediately for care management activities to begin. However, without consent the Health Home care manager cannot share Protected Health Information (PHI). The Health Home care manager can work one–on–one with the member on some care management activities that do not require sharing of PHI until the consent is completed Members who continuously refuse to sign the consent form will eventually need to be disenrolled as the Health Home Program requires coordination between providers

2A: Additional Guidance to Completing the Health Home Patient Information Sharing Consent Form (DOH–5055)

In addition to instructions for completing Member forms provided in Section 1, one of the following options must be used when completing page 3 of the Health Home Patient Information Sharing Consent (DOH–5055).

Options may include:

  • Option 1 – Write in the names of only those downstream providers and other entities approved by the member;
  • Option 2 – List all of the Health Home's downstream partners and add any other entities approved by the member. Use check marks to clearly identify only those providers and others approved by the member. Have the member initial next to each selection; or
  • Option 3 – List all of the Health Home's downstream partners and add any other entities as approved by the member on page 3. Cross out all entities the member does not want involved in his/her care. Have the member initial next to all those crossed out.

NOTE: An additional assurance would be to have the member and the Health Home or care manager sign and date page 3 at the bottom once it is completed.

2B: Making Changes to the Health Home Patient Information Sharing Consent (DOH–5055) after it has been completed and signed

A Health Home member may request to add/remove and/or limit access to information at any time. The care manager must assure that:

  1. Any changes or limitations specified by the member are clearly noted in the DOH–5055;
  2. All page 3´s should be completed in the same format to avoid confusion;
  3. Each change is initialed by the member and dated; and,
  4. Each change is also initialed by the care manager and dated

Section 3: Health Home Patient Information Sharing – Withdrawal of Consent (DOH–5058)

This form is used for a member who is enrolled in the Health Home program and has signed the DOH–5055.

3A: Additional Guidance to Complete the Health Home Patient Information Sharing – Withdrawal of Consent (DOH–5058)

In addition to instructions for completing Member forms provided in Section 1, the care manager must;

  1. Assure all Health Home partners and others approved by the Member on page 3 of the signed DOH–5055 consent are notified of the Member´s disenrollment and the effective date to end information sharing;
  2. Document a member´s refusal to sign the DOH–5058 and notify all Health Home partners and others approved by the Member on page 3 of the signed DOH–5055 consent of member´s request to disenroll and end information sharing.

Section 4: Health Homes Opt–Out form (DOH–5059)

The DOH–5059 form is used during outreach activities to an individual assigned by NYSDOH who does not want to be enrolled in the Health Home Program.

The Health Home Opt Out form (DOH–5059) is not used if:

  1. The individual has enrolled in the Health Home program and has signed the DOH–5055 consent. NOTE: In this case, the DOH–5058 withdrawal form must be used to disenroll the member and end all information sharing previously approved by the member in the DOH–5055; and,
  2. The enrolled member requests transfer to another Health Home. Follow the instructions for transferring members in the Health Home Member Tracking Specifications Document in the Health Home Provider Billing Manual.

4A: Additional Guidance to Complete the DOH–5059

In addition to instructions for completing Member forms provided in Section 1, the care manager must assure the DOH–5059 is completed as follows:

  1. The appropriate Attestation Statement box is checked indicating whether the care manager met with the individual in person, or talked with the individual on the phone.
  2. The individual´s reason(s) for opting out are documented;
  3. The form must be signed and dated by the individual and the care manager.
  4. If the individual is unable or refuses to sign the form, the care manager must document this on the form.