Form Doh 5059 – Fill Out and Use This PDF

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.

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)