Health Home Serving Children (HHSC)

Consent Forms and Templates

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

  • Health Homes Serving Children: Consent Document Guidance - Updated March 2022 (PDF)
    • The Health Homes Serving Children: Consent Document Guidance provides an overview, procedures and useful tips when explaining and completing the required consent forms used in the Health Home Serving Children program (DOH 5201, DOH 5203, DOH 5204, and DOH 5055), and is a companion document to the Access to/Sharing of Personal Health Information (PHI) and the Use of Health Home Consents policy #HH0009, which can be found on the Health Home Policy and Updates page under: Consent.
  • Consent and Policy Webinar Q&A - April 2022 (XLSX)
  • HHSC Policy and Consent Revisions Training Slides - Updated April 2022 (PDF)
    • The training slides address changes in the use of HHSC consent forms and associated policies
  • Consent Policy Chart (PDF)
    • This chart lists the HHSC consent forms, including consent forms eliminated from use (effective May 1, 2022)

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 the Health Home Consent Enrollment and Information Sharing For Use with Children Under 18 Years of Age (DOH 5201) form.

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 for children and adolescents less than 18 years of age who have been enrolled in a Health Home using Health Home Consent Frequently Asked Questions (FAQ) for use with Children and Adolescents Under 18 Years of Age. The DOH 5201 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. If Section 2 cannot be completed for any reason identified in the DOH 5201, then the HHCM must complete the Health Home Care Management Tracking Form For Section 2.

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 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.

When the Health Home enrolls a new member, the DOH-5234 should be completed and mailed with the welcome letter.

Health Home Notice of Determination for Enrollment (DOH 5234) Forms:

When a member is disenrolled, the DOH-5235 must be completed and mailed at least 10 days prior to the date upon which the Health Home proposed action is to take place.

Notice of Determination for Disenrollment in the New York State Health Home Program (DOH 5235) Forms:

If an individual is found ineligible for Health Home services, the DOH-5236 must be mailed to the individual informing them they did not meet the Health Home eligibility criteria.

Notice of Determination for Denial of Enrollment in the New York State Health Home Program (DOH 5236) Forms: