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.
| Question | Answer |
|---|---|
| Form Name | Form Doh 5059 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | nys opt out letter 2021, nys opt out letter 2020, doh opt out form, nys assessment opt out letter |
