Health Home Serving Children (HHSC)

Recent Updates!

Note: The following HHSC consent forms have been revised and replace the October 24, 2016 version as indicated. All other HHSC consent forms remain in use with the effective date of October 24, 2016. Health Homes and Care Management Agencies must begin using these revised consent forms no later than August 1, 2018.
  • Health Home Consent Frequently Asked Questions (FAQ) for use with Children and Adolescents Under 18 Years of Age – REVISED 3/18
  • Health Home Consent Information Sharing For Use with Children and Adolescents Under 18 Years of Age (DOH 5201) – REVISED 3/18
  • Health Home Withdrawal of Health Home Enrollment and Information Sharing Consent Form For Use with Children and Adolescents Under 18 Years of Age (DOH 5202) – REVISED 3/18

Consent Forms and Templates

The following consent forms are approved for use by Health Homes Serving Children (HHSC):

This document should be given to children who are less than 18 years of age and who are eligible to enroll in a Health Home, and to their parents, guardians or legally authorized representatives. This document should be reviewed with them prior to completion of Health Home Consent/Enrollment/For Use with Children Under 18 Years of Age form (DOH 5200) and Health Home Consent/Information Sharing/For Use with Children Under 18 Years of Age form (DOH 5201).

Please note: children who are parents, pregnant, and/or married, and who otherwise are capable of consenting, should not be given this document. They should be given the Health Home Patient Information Sharing Consent form (DOH 5055) to review and complete. Instructions for completing forms are found on the Lead Health Home Resource Center page under Forms and Templates: Click here.

FAQs:

This form must be used to enroll children and adolescents who are less than 18 years of age into a Health Home and must be signed by the child´s parent, guardian, or legally authorized representative. Legally authorized representative for enrollment in a Health Home is defined as: "a person or agency authorized by state, tribal, military or other applicable law, court order or consent to act on behalf of a person in making health care decisions". The Health Home Consent/Information Sharing/For Use with Children Under 18 Years of Age form (DOH 5201), must also be completed after this enrollment form has been completed and signed by all necessary parties.

Please note: children who are parents, pregnant, and/or married, and who otherwise are capable of consenting, must consent for their own enrollment into a Health Home. They should do this by completing the Health Home Patient Information Sharing Consent form (DOH 5055). Instructions for completing forms are found on the Lead Health Home Resource Center page under Forms and Templates: Click here.

This form must be used for children and adolescents less than 18 years of age who have been enrolled in a Health Home using Health Home Consent/Enrollment/For Use with Children Under 18 Years of Age (DOH 5200)*. This form outlines what, and with whom, health information can be shared. Section 1 of this form should be completed by the child´s parent, guardian, or legally authorized representative. Legally authorized representative for the purpose of sharing health information is defined as "a person or agency authorized by state, tribal, military or other applicable law, court order or consent to act on behalf of a person for the release of medical information". Section 2 of this form is completed separately by the child with the care manager.

Please note: children and adolescents who are parents, pregnant, and/or married should not use this form to consent for health information sharing. Rather, they must use the Health Home Patient Information Sharing Consent form (DOH 5055). Instructions for completing forms are found on the Lead Health Home Resource Center page under Forms and Templates: Click here.

This form must be used for children and adolescents less than 18 years of age who have been enrolled in a Health Home and completed Health Home Consent/Enrollment/For Use with Children Under 18 Years of Age form (DOH 5200) and Health Home Consent/Information Sharing/For Use with Children Under 18 Years of Age form (DOH 5201)*. This form is to disenroll from the Health Home and take away consent to release health information for children who have been enrolled in a Health Home. Withdrawal of consent for children under age 18 must be provided by the parent, guardian or legally authorized representative. Legally authorized representative for the purpose of withdrawing consent is defined as "a person or agency authorized by state, tribal, military or other applicable law, court order or consent to act on behalf of a person in making health care decisions".

Please note: children and adolescents who are parents, pregnant, or married should not use this form to disenroll and withdraw consent to release health information. Rather, they must use the Health Home Patient Information Sharing – Withdrawal of Consent form (DOH 5058)]. Instructions for completing forms are found on the Lead Health Home Resource Center page under Forms and Templates: Click here.

This form is for consent to release educational records to a Health Home for children and adolescents who have been enrolled in a Health Home. It includes information on what educational records and with whom educational records can be shared. Consent for release of educational records for children under age 18 must be provided by the parent. Consent for release of educational records for those over age 18 must be provided by the individual.

This form is for withdrawal of consent to release educational records to a Health Home for children and adolescents who have been enrolled in a Health Home. It includes information on what educational records and with whom educational records can be shared. Consent for release of educational records for children under age 18 must be provided by the parent. Consent for release of educational records for those over age 18 must be provided by the individual.

This form must be used for all Medicaid members, children and adults to complete an Assessment Tool within the Uniform Assessment System–NY (UAS–NY). For Health Homes Serving Children, the care manager must obtain consent to conduct the CANS–NY functional assessment from the parent, guardian, legally authorized representative or the child if they can self–consent. Without obtaining this consent, care managers will be unable to complete a CANS–NY in the Uniform Assessment System–NY (UAS–NY)

The Health Home program is voluntary. For members who choose not to enroll 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 forms are found on the Lead Health Home Resource Center page under Forms and Templates: Click here.