Health Home Opt Out Form 5059 Doh
User Manual: 5059
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New York State Department of Health Medicaid Health Home Opt-out Form Attestation Statement For use by Health Home eligible Medicaid client I have met with the care manager for Name of Health Home who has explained the program to me and the care management services I can get. I have decided not to join at this time. For use by care manager I have discussed program with Name of Health Home over the telephone. The benefits of Name of Medicaid Member membership 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 care manager or Health Home services, but I will still continue to get my Medicaid health care services. Name of Member or Client’s Legal Representative (print) Original Signature Date Name of Health Home Care Manager (print) Original Signature Date NOTE If you would ever like to get Health Home services contact the NYS Medicaid Program by calling the Medicaid Call Center at 1-800-541-2831. DOH-5059 (4/12)
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