Form Doh 5059 PDF Details

Understanding the specifics of the DOH 5059 form is crucial for Medicaid clients in New York State who are considering their options regarding Health Home care management and services. This form serves as an official opt-out document for those eligible for but not interested in enrolling in Health Home programs at the current time. It provides a structured way for clients to assert their decision after having a detailed discussion with either a Health Home care manager or a representative from their Medicaid Managed Care Plan about the benefits and offerings of Health Home services. In addition to acknowledging a client's refusal to participate, the form also outlines the necessity for those eligible for Office for People With Developmental Disabilities’ (OPWDD) Home and Community Based Services (HCBS) to enroll in an alternative form of care management should they opt-out of Health Home services. This attestation includes areas for the signature of the client, and if applicable, their parent, guardian, or legally authorized representative, as well as the names and signatures of the care manager or Medicaid Managed Care Plan representative who provided the program information. Moreover, the document ensures clients are aware they can opt into Health Home services in the future if they change their mind, detailing contact information for easy access to enrollment. The DOH 5059 form stands as a critical tool for aligning a client's healthcare services with their personal choices and needs.

QuestionAnswer
Form NameForm Doh 5059
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnys opt out letter 2021, nys opt out letter 2020, doh opt out form, nys assessment opt out letter

Form Preview Example

New York State Department of Health Medicaid

Health Home Opt-out Form

Attestation Statement

For use by Health Home eligible Medicaid client

I have met with the Health Home care manager for

Name of Health Home

or representative from my Medicaid Managed Care Plan

Name of Medicaid Managed Care Plan

who has explained the Health Home program to me and the Health Home care management services I can get. I have decided not to join the Health Home program at this time.

For use by Health Home Care Manager or Medicaid Managed Care Plan Representative

I have discussed the Health Home program with

Name of Medicaid Client

over the telephone. The benefits of Health Home services were explained; however, the Medicaid client has decided not to join at this time.

Reason for Opting Out

Signatures

I understand that I will not get a Health Home care manager or Health Home services.

I also understand that if I am eligible for Office for People With Developmental Disabilities’ (OPWDD) Home and Community Based Services (HCBS) and I have opted out of Health Home services, I will need to enroll in an alternate form of care management in order to receive HCBS services.

Name of Medicaid Client (print)

 

Original Signature of Medicaid Client

 

Date

 

 

 

 

 

Name of Medicaid Client’s Parent, Guardian, or

 

Original Signature of Medicaid Client’s Parent, Guardian, or

 

Date

Legally Authorized Representative, if applicable (print)

 

Legally Authorized Representative, if applicable

 

 

 

 

 

 

 

Name of Health Home Care Manager (print)

 

Original Signature of Health Home Care Manager

 

Date

 

 

 

 

 

Name of Medicaid Managed Care Plan Representative (print)

 

Original Signature of Medicaid Managed Care Plan

 

Date

 

 

Representative

 

 

NOTE

If you would ever like to get Health Home services, contact the New York State Medicaid Program by calling the Medicaid Call Center at 1-800-541-2831, or your Medicaid Managed Care Plan.

DOH-5059 (4/19)

How to Edit Form Doh 5059 Online for Free

You'll find nothing challenging about filling out the 2020 nys opt out letter once you begin using our PDF tool. Following these basic steps, you will get the ready PDF document within the minimum period possible.

Step 1: Press the "Get Form Now" button to begin.

Step 2: After you've accessed the 2020 nys opt out letter edit page, you'll see all functions you can use regarding your file at the upper menu.

Type in the details requested by the system to complete the form.

new york state test opt out letter empty spaces to complete

In the part I also understand that if I am, Name of Medicaid Client print, Original Signature of Medicaid, Name of Medicaid Clients Parent, Original Signature of Medicaid, Name of Health Home Care Manager, Original Signature of Health Home, Name of Medicaid Managed Care Plan, Original Signature of Medicaid, Date, Date, Date, Date, NOTE, and If you would ever like to get note the information that the system requests you to do.

step 2 to completing new york state test opt out letter

Step 3: When you have selected the Done button, your form should be available for upload to any kind of gadget or email address you specify.

Step 4: You should make as many copies of your file as you can to stay away from future complications.

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