The final version of the Health Home Patient Information Consent Form has been posted on the Health Home website.
Health Home Consent Form Posted
NYS Department of Health January 27, 2012
The attached Health Home Patient Consent Form is required to officially enroll all Health Home eligible members in a Health Home program. New York State expects case managers to complete this form with the eligible members to assure they can read and understand it. Health Homes will have three months to enroll assigned members in the Health Home after which time the Health Hom will no longer be able to receive payments for a member who has not signed the patient consent form.
If there are changes in the Health Home participating partners, another patient consent form will need to be secured by that Health Home. By completing this consent form, a member is agreeing to participate and be enrolled in the Health Home program and to allow their health information to be shared among the Health Home partners, including a Regional Health Information Organization (RHIO). If a member withdraws their consent to share health information, then they are withdrawing from the Health Home program and must sign a Withdrawal of Consent Form.
NOTE: Health Homes that intend to form new Health Home corporations must be mindful of how the consent form is filled out and how the new corporation is structured, to avoid the need to secure a new patient consent form for the new corporation. For example, Health Homes may want members to enroll in the Health Home under its current name as well as the name that the Health Home expects to operate under in the near future.
- Health Home Patient Information Sharing Consent Form (PDF, 40KB, 3pg.)
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/forms/