Form DOH-5055 Health Home Patient Information Sharing Consent - New York

What Is Form DOH-5055?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form DOH-5055?
A: Form DOH-5055 is the Health Home Patient Information Sharing Consent specific to the state of New York.

Q: What is the purpose of Form DOH-5055?
A: The purpose of Form DOH-5055 is to obtain consent from the patient to share their health information with designated Health Home providers in order to facilitate coordinated care.

Q: Who needs to fill out Form DOH-5055?
A: The patient or their legally authorized representative needs to fill out Form DOH-5055.

Q: What information is required on Form DOH-5055?
A: Form DOH-5055 requires information such as the patient's name, date of birth, address, and the names of the designated Health Home providers.

Q: Can I revoke my consent on Form DOH-5055?
A: Yes, you can revoke your consent at any time by completing a new Form DOH-5055 with the revocation section filled out.

Q: Do I need to provide consent for every Health Home provider separately?
A: No, you only need to provide consent once on Form DOH-5055 for all designated Health Home providers.

Q: What happens if I do not provide consent on Form DOH-5055?
A: If you do not provide consent on Form DOH-5055, your health information will not be shared with the designated Health Home providers, and they may not be able to coordinate your care effectively.