Health Homes Serving Children Consent Document Guidance

March 20, 2017

  • Guidance is also available in Portable Document Format (PDF)

The purpose of this guidance is to provide important information regarding the proper utilization of the required consent forms needed for Children´s Health Homes.

Proper consents are required to refer, share information and enroll a member in a Children´s Health Home and complete the Child and Adolescent Needs and Strengths (CANS-NY) Assessment within the Uniformed Assessment System (UAS-NY). Health Home Care Managers who are responsible for obtaining consent, must be knowledgeable of the specific federal and New York State legal protections for minors related to minor consent. In addition, the Health Home Care Manager must be mindful of who is the responsible party able to provide consent, i.e., the parent, guardian, legally authorized representative or in some cases, the child/adolescent. Additionally, there are instances where both the parent, guardian, legally authorized representative and the child/adolescent must provide consent.

Providers that make a referral to the Health Homes Serving Children program, are responsible for obtaining verbal consent to refer within the Medicaid Analytics Performance Portal Health Home Tracking System (MAPP HHTS) Children´s Referral Portal. Once a referral is completed, the assigned care managers are responsible for educating the child and/or their parent, guardian, or legal authorized representative, about the Children´s Health Home program and the plan of care process. Prior to enrollment, the care manager should ensure that the child and/or parent, guardian and legal authorized representative has received and understood the consent forms, and the consent process for their protected health information (PHI). Additionally, it is the care manager´s responsibility to explain and assist the child/adolescent, parent, guardian, or legally authorized representative, in the completion of all the required consent forms.

Note: A new consent to enroll and information sharing is required when:

  • The child/adolescent changes Health Homes
  • Health Home program name changes
  • The child/adolescent dis–enrolls and re–enrolls
  • The child/adolescent turns 18 years old, only if he/she did not previously consent for him/herself
  • The child/adolescent changes from foster care to non–foster care or non– foster care to foster care
  • The child/adolescent gets married, becomes pregnant or becomes a parent

Overview of Individuals Who Can Provide Consent

For individuals who are between 18–21 years of age or children under 18 years of age who are parents, pregnant, and/or married:

Individuals who are 18–21 years of age are able to legally consent for their own enrollment into a Children´s Health Home program. Children and adolescents who are parents, pregnant, married, are legally able to consent for their own enrollment into a Health Home and share their protected health information.

For children and adolescents who are under 18 years of age and who are NOT parents, pregnant and/or married:

Children and adolescents who are not parents, pregnant, and/or married are unable to legally consent for their own enrollment into a Children´s Health Home. This must be done by the child´s parent, guardian, or legally authorized representative. This is explained in more detail below. However, for the purposes of information sharing, provision of consent is either by the parents, guardians, legal representative, the child and/or both.

A legally authorized representative, for the purpose of enrolling and/or information sharing 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".

Types of Required Consent

A. Consent to Refer

Prior to referring a member to the Children´s Health Home program, the referrer must obtain at least verbal consent from a parent, guardian, legally authorized representative and/or the child/adolescent, if appropriate, as referenced above. (Providers may follow their own procedures with making a referral for health services provided at least verbal consent is obtained). Consent to refer is documented in the Medicaid Analytics Performance Portal Health Home Tracking System (MAPP HHTS) Children´s Referral Portal, when the referring entity indicates who has provided consent to refer. This verbal consent is needed to ensure that the consenter is aware a referral has been made for the Health Home program and is prepared to engage when they are contacted by the assigned Health Home care manager.

B. Health Home Consent Frequently Asked Questions (FAQ) For Use with Children Under 18 Years of Age

The child/adolescent and the parent, guardian or legally authorized representative must be provided a copy of Health Home Consent Frequently Asked Questions (FAQ) For Use with Children Under 18 Years of Age which explains the Health Home program and services, and consent for information sharing and Health Home enrollment.

C. Health Homes Opt–Out Form (Form DOH 5059)

This form is utilized by the Health Home Care Manager during outreach activities to document that the consenter (the child and/or their parent, guardian, or legal authorized representative) has declined to enroll in the Health Home program. For the Health Home Serving Children´s program, it is a Health Home standard that when the consenter declines to enroll in the Health Home program, that the care manager contacts the referral source to notify them that the consenter has declined to enroll in the Health Home program.

D. Health Home Consent Enrollment (Form DOH 5200) For Use with Children Under 18 Years of Age

The Health Home Consent Enrollment (Form DOH 5200) should be completed and signed, only, by a parent, guardian, or legally authorized representative of children under the age of 18 for enrollment into the Health Home Serving Children program. It is important for the consenter to understand that the child/adolescent will be enrolled in Health Home, a program that provides care management services, as well as the requirements for services to be delivered (i.e., the completion of the CANS–NY) and potentially a monthly face–to–face meeting. Additionally, enrollment in Health Home services will continue until such time the consenter withdraws enrollment or the multidisciplinary team along with the consenter believe that Health Home services are no longer needed and the child/adolescent is dis–enrolled.

E. Health Home Consent Information Sharing (Form DOH 5201) For Use with Children Under 18 Years of Age

This form has two sections, section one for the parents, guardians or legally authorized representative to complete and section two for the child/adolescent to complete separately with the Health Home care manager.
Section 1:
To be completed, only, by the parents, guardians or legally authorized representative of children under the age of 18. The parents, guardians or legally authorized representative should be informed that:
  • Health providers may share information before or after the signature date on the consent form.
  • Consent to share information can be recorded, modified and withdrawn at any time.
  • The child can keep private any information about services that the child/adolescent has the right to self– consent to receive (see Section 2).
Section 2:
To be completed, only, by the child/adolescent separately with the Health Home care manager and not with the parents, guardians, or legally authorized representative.

The child/adolescent can keep private any of their information regarding family planning, emergency contraception, abortion, sexually transmitted infection testing and treatment, HIV testing, prenatal care, labor and delivery services, drug and alcohol treatment, or sexual assault services. Consent to share information regarding these types of protected services is applicable to children/adolescents aged 10 years or older. If the child/adolescent is unable or unwilling to complete section 2 of Health Home Consent Information Sharing (Form DOH 5201), it should be left blank and document reason why it was not completed. In addition, if child/adolescent is specifically receiving mental health services and is over the age of twelve, the mental health provider may ask the child/adolescent if they want their information disclosed.

If the parent, guardian, or legally authorized representative consented for these services (mentioned above) on behalf of the child/adolescent, then the parent, guardian, or legal authorized representative may have the authority to consent for the release of information for these services. However, the child/adolescent must also consent to the release of this information.

F. Health Home Withdrawal of Health Home Enrollment and Information Sharing Consent Form (Form DOH– 5202) For Use with Children Under 18 Years of Age

To be completed by parents, guardians, or legally authorized representative of children/adolescents under the age of 18, to dis–enroll from the Health Home Program and rescind consent to release health information for children/adolescents who have been enrolled in a Health Home.

G. Health Home Release of Educational Records Consent Form (Form DOH 5203) For ALL Individuals in Health Home Program

To be completed by the parent of a child/adolescent under the age of 18 (see definition of parent on the consent form) or the child/adolescent if 18 years of age or older, to consent to share education records.

New York State Education (NYSED) requires a different consent to release educational records because they are covered by Family Educational Rights and Privacy Act (FERPA) and not the Health Insurance Portability and Accountability Act (HIPAA). The definition of parent in DOH 5203 is also different from other Health Home consent forms. Please refer to DOH 5203 for the complete definition of parent, guardian or legally authorized representative.

Note: This will also include education records that are directly related to an infant or toddler in the Early Intervention Program (EIP) or records from a local early intervention official.

H. Health Home Withdrawal of Release of Educational Records (Form DOH 5204) For All Individuals in Health Home Program

To be completed by the parent of a child/adolescent under the age of 18 (see definition of parent on the consent form) or the child/adolescent if 18 years of age or older, to withdraw consent to share educational records. Education records need a separate form if they are covered under Family Educational Rights and Privacy Act (FERPA) and not the Health Insurance Portability and Accountability Act (HIPAA).

I. Patient Information Sharing Consent (Form DOH 5055) for Individuals 18 years of age or older or a child/adolescent if a parent, pregnant or married

To be completed by an individual to provide consent for enrollment in a Health Home and for the purpose of sharing health information. Children/adolescents who are 18 years of age or older or are a parent, pregnant or married, are legally able to consent for their own enrollment into a Health Home and share their information.

Therefore, DOH 5200 and DOH 5201 are not needed if DOH 5055 is completed.

J. Health Home Patient Information Sharing Withdrawal of Consent (Form DOH 5058) for Individuals 18 years of age or older or child/adolescent if parent, pregnant, or married

This form rescinds the consent to enroll and consent to release health information for people over the age of 18 and children/adolescents who are parents, pregnant, or married. These individuals can withdraw from the Health Home program at any time by using this form.

K. Functional Assessment Consent Form (DOH 5230) For Use with ALL Enrolled Health Home Serving Children´s program children/adolescents up to the age of 21 years´ old

Upon enrollment into a Children´s Health Home, the care manager must obtain this consent to conduct the Child and Adolescent Needs and Strengths–New York (CANS–NY) assessment tool. This consent must be signed by a parent, guardian, or legally authorized representative if child/adolescent is under the age of 18 or by the child, if a parent, pregnant and/or married. Individuals who are between 18 and 21 years of age, can provide consent on their own behalf.

The Functional Assessment Consent Form (DOH 5230) is needed to enter the members identifying information into the Uniform Assessment System–New York (UAS–NY) database. Without obtaining this consent, the Health Home care manager will not be able to complete a Child and Adolescent Needs and Strengths–New York (CANS–NY) assessment in the Uniform Assessment System–New York (UAS–NY) system.
Health Home Serving Children consent forms of FAQ:
Additional Health Home consent forms:
  • Health Home Patient Information Sharing Consent (DOH–5055),
  • Health Home Patient Information Sharing – Withdrawal of Consent (DOH–5058) and
  • Health Home Opt–Out (DOH–5059)