Form Doh-5055 - Health Home Patient Information Sharing Consent - New York Department Of Health
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1
2
3NEW YORK STATE DEPARTMENT OF HEALTH
Health Home Patient Information Sharing Consent
Medicaid
Name of Health Home
By signing this form, you agree to be in the
Health Home.
To be in a Health Home, health care providers and other people involved in your care need to be able to talk to each other about your care and
share your health information with each other to give you better care. While being in a Health Home will help make sure you get the care you
need, you will still be able to get health care and health insurance even if you do not sign this form or do not want to be in the Health Home.
The Health Home may get your health information, including your health records, from partners listed at the end of this form and/or from others
through a computer system run by the
,
a Regional Health Information Organization (RHIO) and/or a computer system called PSYCKES run by the New York State Office of Mental
Health. A RHIO uses a computer system to collect and store your health information, including medical records, from your doctors and health
care providers who are part of the RHIO. The RHIO can only share your health information with the people who you say can see or get your health
information. PSYCKES is a computer system to collect and store your health treatment from your doctors and health care providers who are part of
the Medicaid program.
If you agree and sign this form, the Health Home and the partners listed on this form are allowed to get, see, read and copy, and share with each
other, ALL of your health information (including all of your health information the Health Home obtains from the RHIO and/or from PSYCKES)
that they need to give you care, manage your care or study your care to make health care better for patients. The health information they may get,
see, read, copy and share may be from before and after the date you sign this form, Your health records may have information about illnesses or
injuries you had or may have had before; test results, like X-rays or blood tests; and the medicines you are now taking or have taken before. Your
health records may also have information on:
1. Alcohol or drug use programs which you are in now or were in before as a patient;
2. Family planning services like birth control and abortion;
3. Inherited diseases;
4. HIV/AIDS;
5. Mental health conditions; and/or
6. Sexually-transmitted diseases (diseases you can get from having sex).
Your health information is private and cannot be given to other people without your permission under New York State and U.S. laws and rules.
The partners that can get and see your health information must obey all these laws. They cannot give your information to other people unless you
agree or the law says they can give the information to other people. This is true if your health information is on a computer system or on paper.
Some laws cover care for HIV/AIDS, mental health records, and drug and alcohol use. The partners that use your health information and the Health
Home must obey these laws and rules.
Please read all the information on this form before you sign it.
I AGREE to be in the
Health Home and
agree that the Health Home can get ALL of my health information from the partners listed at the end of this form and from others through
RHIO and/or through PSYCKES to give me care or manage my care, to
check if I am in a health plan and what it covers and to study and make the care of all patients better. I also AGREE that the Health Home and
the partners listed at the end of this form may share my health information with each other. I understand this Consent Form takes the place of
other Health Home Patient Information Sharing Consent Forms I may have signed before to share my health information. I can change my mind
and take back my consent at any time by signing a Withdrawal of Consent Form (DOH-5058) and giving it to one of the Health Home partners.
Print Name of Patient
Patient Date of Birth
Signature of Patient or Patient’s Legal Representative
Date
Print Name of Legal Representative
Relationship of Legal Representative to Patient
(If Applicable)
(If Applicable)
DOH-5055 (12/13) p 1 of 3
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