Get Doh 5058

The Doh 5058 form is essential for individuals wishing to withdraw their consent from the Health Home program in New York. This guide will provide clear, step-by-step instructions to help you navigate the online process effortlessly.

Follow the steps to fill out the Doh 5058 online.

1. Click the ‘Get Form’ button to access the Doh 5058 form and open it in your preferred online editor.
2. Enter the name of the Health Home Provider Organization in the designated field. Ensure that the organization’s name is spelled correctly.
3. Indicate your intention to withdraw from the Health Home program by affirming your understanding of the implications mentioned in the form.
4. Provide your full name in the 'Print Name of Patient' section to confirm your identity.
5. Fill in your date of birth accurately to validate your personal information.
6. Sign the form by adding your signature in the 'Signature of Patient or Patient’s Legal Representative' section.
7. Enter the date of your signature to ensure that there is a record of when the withdrawal was made.
8. If applicable, print the name of the legal representative who is signing on your behalf, along with their relationship to you.
9. Review the completed form for any errors or omissions before proceeding to submit it.
10. Once you have verified that all information is correct, save changes, download, print or share the form according to your needs.

Take action today and complete the Doh 5058 form online for a smooth withdrawal process.