Health Home Opt Out Form 5059 Doh
User Manual: 5059
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New York State Department of Health
Medicaid
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
Name of Health Home
program with 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.
Health Home Opt-out Form
DOH-5059 (4/12)
