Get Doh 5058 2020-2025

Filling out the Doh 5058 form is a crucial step for individuals participating in the Health Home program. This guide provides clear and detailed instructions on how to complete the form effectively online.

Follow the steps to complete the Doh 5058 form online.

1. Click ‘Get Form’ button to obtain the Doh 5058 and open the document.
2. Begin by filling in the program name for the Health Home in the designated field.
3. Provide your name and surname in clear printed letters in the appropriate section of the form.
4. Enter the date of birth of the patient accurately. Ensure that the format aligns with any requirements specified in the form.
5. Sign the form in the section designated for the patient's signature or that of their legal representative, if applicable.
6. Include the date of signing the form in the provided field.
7. If applicable, fill in the name of the legal representative in printed letters.
8. Specify the relationship of the legal representative to the patient, if necessary.
9. Review all entered information for accuracy and completeness before finalizing your submission.
10. Once all fields are completed, save the changes, download the form, print it, or share it as needed.

Complete the Doh 5058 form online today to ensure your participation in the Health Home program.